Interesting Case Presentation March 1, 2012 Franklin C. Margaron, MD

HPI- TRJNotum 66 yo male initially presenting 2/9 for a crush and degloving injury to his left hand at work, no other trauma 66 yo male initially presenting 2/9 for a crush and degloving injury to his left hand at work, no other trauma PMH: Hypercholesterolemia PMH: Hypercholesterolemia PSH: None PSH: None Meds: Simvastatin Meds: Simvastatin All: NKDA All: NKDA Soc Hx: Denies EtOH, smoking Soc Hx: Denies EtOH, smoking

To OR 2/9 for complex laceration repair, ORIF, and integra placement To OR 2/9 for complex laceration repair, ORIF, and integra placement Initially on Lovenox for 2 days, then this was discontinued. Pt on ASA 325, statin, ancef Initially on Lovenox for 2 days, then this was discontinued. Pt on ASA 325, statin, ancef Pt intermittently ambulatory but left hand in stockinette suspended from IV pole while in bed Pt intermittently ambulatory but left hand in stockinette suspended from IV pole while in bed 2/17 returned to OR for debridement, Integra placement 2/17 returned to OR for debridement, Integra placement Kept in hospital for complex wound care Kept in hospital for complex wound care

2/24 while walking had syncopal episode 2/24 while walking had syncopal episode Apneic, cyanotic, unresponsive for 3 min Apneic, cyanotic, unresponsive for 3 min BVM initiated, pulse ox 91% BVM initiated, pulse ox 91% Awoke spontaneously and became appropriate and conversive Awoke spontaneously and became appropriate and conversive c/o some pain in left lower chest c/o some pain in left lower chest SBP 100, HR 130s, RR 30s, sats 93% on 4L NC SBP 100, HR 130s, RR 30s, sats 93% on 4L NC EKG sinus tach EKG sinus tach Troponin 0.4->1.22 Troponin 0.4->1.22 PE CT ordered PE CT ordered

TTE: TTE: Moderate to severe reduction in right systolic function Moderate to severe reduction in right systolic function Mild right atrial and ventricular dilation Mild right atrial and ventricular dilation Flattening of interventricular septum Flattening of interventricular septum Mild reduction in left systolic function Mild reduction in left systolic function CT surgery consulted CT surgery consulted Heparin gtt initiated Heparin gtt initiated Pt taken for emergent for pulmonary embolectomy with cardiopulmonary bypass Pt taken for emergent for pulmonary embolectomy with cardiopulmonary bypass

Initially transferred to ICU on 2 pressors Initially transferred to ICU on 2 pressors Venous duplex revealed bilateral LE DVT and pt underwent IVC filter placement Venous duplex revealed bilateral LE DVT and pt underwent IVC filter placement Hypercoagulable workup initiated Hypercoagulable workup initiated Extubated 2/26 Extubated 2/26 Weaned off pressors 2/27 Weaned off pressors 2/27 Currently On floor tolerating diet, >97% on 2L NC, HR 90s, SBP 140s Currently On floor tolerating diet, >97% on 2L NC, HR 90s, SBP 140s Repeat TEE: EF 50%, mild reduction in systolic function, no pulmonary hypertension Repeat TEE: EF 50%, mild reduction in systolic function, no pulmonary hypertension

Pulmonary Embolectomy Massive PE has up to 70% mortality within the first hour Massive PE has up to 70% mortality within the first hour HD instability HD instability >50% occlusion of PA >50% occlusion of PA Right heart strain on Echo Right heart strain on Echo 90 day mortality following PE- 17.4% 90 day mortality following PE- 17.4%

Review looking at 1742 studies on PE and management strategies Review looking at 1742 studies on PE and management strategies Heparin anticoagulation universal Heparin anticoagulation universal Roles of thrombolysis and embolectomy (catheter, surgical) not well defined Roles of thrombolysis and embolectomy (catheter, surgical) not well defined Surgical embolectomy traditionally reserved for Surgical embolectomy traditionally reserved for Severe RV dysfunction Severe RV dysfunction Failure of thrombolysis Failure of thrombolysis Contraindication to thrombolysis Contraindication to thrombolysis Improvements in operative techniques and ICU care have significantly decreased mortality from surgical thrombectomy Improvements in operative techniques and ICU care have significantly decreased mortality from surgical thrombectomy Complications related to thrombolysis Complications related to thrombolysis Hemorrhage Hemorrhage Fragmentation with distal lodging causing pulmonary hypertension Fragmentation with distal lodging causing pulmonary hypertension

Several randomized controlled trials looking at thrombolysis vs heparin Several randomized controlled trials looking at thrombolysis vs heparin No reduction in 90 day mortality or PE recurrence (6.7% vs. 9.6%; 95% CI 0.40–1.12) No reduction in 90 day mortality or PE recurrence (6.7% vs. 9.6%; 95% CI 0.40–1.12) Subgroup analysis in one meta-analysis (Wan et al. – 11 RCTs) Pts with HD compromise did have reduction in mortality and PE recurrence (9.4% vs. 19.0%; 95% CI 0.22–0.92) Subgroup analysis in one meta-analysis (Wan et al. – 11 RCTs) Pts with HD compromise did have reduction in mortality and PE recurrence (9.4% vs. 19.0%; 95% CI 0.22–0.92) No difference in major bleeding (9.1% vs. 6.1%; 95% CI 0.81–2.46) No difference in major bleeding (9.1% vs. 6.1%; 95% CI 0.81–2.46) Statistically significant difference in minor bleeding (22.7% vs. 10.0%; 95% CI 1.53–4.54) Statistically significant difference in minor bleeding (22.7% vs. 10.0%; 95% CI 1.53–4.54)

Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treatment for massive pulmonary embolism. Eur J Cardiothorac Surg 1994;343:576–560 Thrombolysis vs Surgical embolectomy Thrombolysis vs Surgical embolectomy mortality rate (33% vs. 23%), mortality rate (33% vs. 23%), major hemorrhage (25% vs. 15%) major hemorrhage (25% vs. 15%) PE recurrence rates (21% vs. 7.7%) PE recurrence rates (21% vs. 7.7%)

Meneveau N et al. In-hospital and long-term outcome after submassive and massive pulmonary embolism submitted to thrombolytic therapy. Eur Heart J 2003;24:1447– pts surviving acute phase of PE thrombolysis 227 pts surviving acute phase of PE thrombolysis 56% survival at 10 years 56% survival at 10 years 36% with PE-related events 36% with PE-related events Recurrent DVT Recurrent DVT Recurrent PE Recurrent PE CHF class III-IV CHF class III-IV 15-25% have only partial resolution of clot leading to persistent pulmonary Htn and increased mortality 15-25% have only partial resolution of clot leading to persistent pulmonary Htn and increased mortality

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines: 2012 Low dose unfractionated heparin Low dose unfractionated heparin 18% reduction in the odds of death from any cause 18% reduction in the odds of death from any cause 47% reduction in the odds of fatal PE 47% reduction in the odds of fatal PE 41% reduction in the odds of nonfatal PE 41% reduction in the odds of nonfatal PE 57% increase in the odds of nonfatal major bleeding 57% increase in the odds of nonfatal major bleeding LMWH LMWH reduced the risk of clinical PE and clinical VTE by 70% reduced the risk of clinical PE and clinical VTE by 70% 50% increase in odds of major bleeding and hematoma 50% increase in odds of major bleeding and hematoma

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines: RCTs comparing LDUH and LMWH 51 RCTs comparing LDUH and LMWH >48,000 general and abdominal surgical patients >48,000 general and abdominal surgical patients risk of VTE was 30% lower in the LMWH groups risk of VTE was 30% lower in the LMWH groups difference was not apparent when the analysis was restricted to blinded, placebo-controlled trials difference was not apparent when the analysis was restricted to blinded, placebo-controlled trials No difference in No difference in Clinical PE Clinical PE Death from any cause Death from any cause Major bleeding Major bleeding Wound hematoma Wound hematoma

Conclusions DVT prophylaxis is an imperative step in the management of surgical patients DVT prophylaxis is an imperative step in the management of surgical patients Massive PE has high mortality and needs to be treated early and aggressively Massive PE has high mortality and needs to be treated early and aggressively Surgical pulmonary embolectomy is now the preferred management strategy for patients with HD compromise or evidence of significant right heart strain Surgical pulmonary embolectomy is now the preferred management strategy for patients with HD compromise or evidence of significant right heart strain