Chest
Volume 120, Issue 1, July 2001, Pages 120-125
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Clinical Investigations
Pulmonary Embolism
Thrombolysis or Heparin Therapy in Massive Pulmonary Embolism With Right Ventricular Dilation: Results From a 128-Patient Monocenter Registry

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Study objectives

To assess the potential benefit ofthrombolysis in patients with massive pulmonary embolism (PE) withstable hemodynamics and right ventricular dysfunction.

Design

Retrospective, cohort study.

Setting

University-based, tertiary referral medicalcenter.

Patients

One hundred fifty-three consecutivepatients with massive PE from January 1992 to December 1997 treatedwith heparin or thrombolysis.

Measurements andresults

Massive PE was confirmed by perfusion lung scan orpulmonary angiography. Right ventricular dysfunction was assessed byechocardiography (right ventricular/left ventricular [RV/LV]diastolic diameter ratio > 0.6) in all patients. In order to study ahomogeneous population, 64 patients treated with thrombolysis (group 1)were matched on baseline RV/LV diameter ratio to 64 patients treatedwith heparin (group 2). Perfusion lung scan was repeated at day 7 today 10. Mean relative improvement in perfusion lung scans was higher ingroup 1 than group 2 (54% vs 42%, respectively). PE recurrences werethe same in both groups (4.7%; n = 3). There were no bleedingcomplications and no deaths in group 2. Conversely, in group 1, 15.6%(n = 10) of patients suffered from bleeding (4.7%; n = 3 withintracranial bleeding) and 6.25% (n = 4) of them died.

Conclusions

The results of this monocenter registry do notsupport the indication for thrombolysis in patients suffering frommassive PE with stable hemodynamics and right ventricular dysfunction. Appropriate therapy in such patients still remains unknown. Furtherprospective randomized trials should beperformed.

Section snippets

Patients

From January 1992 to December 1997, 153 consecutive patients with massive PE were admitted to the ICU of the cardiology department and were treated either with thrombolysis (n = 80) or heparin (n = 73).

Results

The baseline characteristics of the two groups of patients were similar, as shown in Table 1. The mean age of the patients was 72 ± 12 years. Approximately 15% of them had a previous PE history. Pulmonary arterial systolic pressure was 56 ± 12 mm Hg, and mean RV/LV ratios were 0.80 and 0.81, respectively. Lung scan defect was higher in group 1 (thrombolysis; 46 ± 10%) than in group 2 (heparin; 43 ± 11%) but without significant difference.

Mean relative improvement in perfusion lung scan defect

Discussion

Doppler echocardiography is particularly useful for detection of right ventricular dysfunction in severe or massive PE.12,13 RV/LV end-diastolic diameter ratio, though not commonly used in North America, has been validated in various studies as a very sensitive criterion for the diagnosis of PE severity. Come14 showed a good correlation between the RV/LV end-diastolic diameter ratio measured in parasternal view and the percentage of vascular obstruction. Fournier et al15showed, in a series of

Conclusion

Despite several limitations regarding its retrospective design and the small number of included patients, the results of this case-controlled study do not favor thrombolysis in patients suffering from massive PE with stable hemodynamics and right ventricular dysfunction. To demonstrate which treatment, thrombolysis or heparin, has the best efficacy/safety profile will require a large-scale, prospective randomized trial.

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