1. 1/31/2019
Pulmonary Embolism
Jan Tomis, 2018

2. 1/31/2019
Pulmonary embolism
Obstruction of (branches) pulmonary arteries with embolus (less commonly with other material – tumour, air, foreign bodies, fat
Acute pulmonary embolism → obstruction of pulmonary arteries → ↑ pulmonary vascular resistence → pulmonary artery pressure → acute right ventricule failure → ↓ CO → shock - potentially fatal
Acute/subacute/chronic (CTEPH) presentation

3. Pulmonary embolism
In most cases (99%) venous tromboembolism – other forms (fat, foreign body, air embolism are very rare)
Origin of emboli in proximal lower extremity veins – iliac,femoral, popliteal
Other sources are rare (upper extremity veins, renal vein)
Virchow triad - venous stasis, endothelial injury, and a hypercoagulable state

4. Epidemiology Incidence circa 50-100 cases per 100000 a year
deaths anually in Europe
1 year mortality after pulmonary embolism estimated at 10-13%

5. Symptoms
Wide range of symptoms – asymptomatic patiets (incident finding on CT) v.s. hemodynamic shock
(SUDDEN ONSET) DYSPNOE!!!!
Chest pain - pleuritic (with periferal emboli and infarction) v.s. stenocardia (central emboli with RV ischemia)
Shock, syncope, hypotension
Hemoptysis, palpitations, caught

7. Risk factors
Inherited – hypercoagulation (FV Leiden, prothrombin mutation, factor C and S deficiency)
Acquired – recent surgery, trauma, initiation of hormonet herapy, active cancer, obesity, heavy cigarette smoking, older age, generally any severe internal comorbidity (heart failure, COPD, pneumonia, infection, dehydration …. )

8. Pathophysiology

9. Diagnosis- stable patients

10. Diagnosis – D - dimer
D-dimer – product of fibrinolysis – not specific, however negative result safely rule out pulmonary embolism (99,5 % negative predictive value)
Random positive result DOES NOT mean pulmonary embolism – elevation od D dimer level in many clinicalsituation (infection, sepsis, trombosis, cancer, heart failure, myocardial infarction, pregnancy… )

11. Diagnosis – CT pulmonary angiography
Gold standard of diagnosis
Shows absence of contrast filling of affected pulmonary artery branches

12. Predictive scores

13. Predictive scores

14. Diagnosis- unstable patients

15. Diagnosis - echocardiography
Right ventricule dilation and systolic dysfunction
Pulmonary hypertension
Intracardiac trombi
D shape (of left ventricle)
McConnell sign
Normal echocardiographic finding does not rule out pulmonary embolism per se, but makes a pulmonary embolism as a cause of hemodynamic instability highly improbable
Differential diagnosis of other causes of cardiogenic shock

17. Classification
The clinical severity of pulmonary embolism does not strictly correlate to mass of pulmonary emboli – small embolisationmight cause hemodynamic compromise inpatient with severe preexisting cardiopulmonary morbidity

18. Classification

19. Classification

20. Therapy- non high-risk PE
Oxygen, antikoagulant therapy
LMWH
3 months in provoked pulmonary embolism, at least three months in unprovoked (usually 6 months), permanent anticoagulation in recurrent PE or in hereditary thrombogenic mutations
Venous filters?
Preparát
Dávkování
Enoxaparine
1.0 mg/ kg
2x / day
1.5 mg/ kg 1x
Nadroparine
86 IU/ kg 2x
Dalteparine
100 IU/ kg
200 IU/ kg
Fondaparinux
5 mg (t.h. < 50kg)
7,5mg (t.h kg)
10 mg (t.h. >100 kg)

21. NOAC VKA in severe renal function impairement Drug Dosing Pretreatment
Dabigatran
150 mg 2x / day
After day LMWH
Apixaban
10 mg 2x / day for 7 days, than 5 mg 2x /day
No pretreatment with LMWH
Rivaroxaban
15 mg 2x / day for 21 days, than 20 mg 1x /day
Edoxaban
60 mg 1x/ day
After 5 day LMWH

22. Therapy- high – risk PE
Oxygen, inotropes, vasopressors, arteficial pulmonary ventilation, ECMO…
Anticoagulant therpay – Heparine – 80 IU/kg bolus, 18IU/kg/h continous administration
Trombolysis:
In thrombolysis contraindiation, consider surgical thrombectomy (high risk procedure, no experiences in most hospitals … extremely rare), selective thrombolysism catheter thrombectomy/aspiration, ECMO
Preparát
Dávkování
rtPA (alteplase, Actilyse)
100mg in 2 hours
0,6 mg/kg in 15 minutes

23. CTEPH
Rare consequence of PE (5/ ) . 80% patients have clinical history of VTE, risk factors – inadequate anticoagulation, recurent PE, high embolic burden, Lupus anticoagulans, hig level FVIII.
Fibrotic organisation of emboli
PAMP > 25 mm Hg after 3 months of anticoagulant therapy , PCW < 15 mm Hg and at least one segmental perfusion defect at ventilation perfusion scintigraphy

24. CTEPH Treatment of choice – pulmonary endarterectomy - NYHA II-IV.
Oxygen therapy, diuretics, permanent anticoagulation
No sufficient evidence of benefic of caval filter implantation