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Impact of Morphologic Characteristics of Central Pulmonary Thromboemboli in Massive Pulmonary Embolism

      Study objective

      To assess the impact of morphologically different central pulmonary artery thromboemboli in patients with massive pulmonary emboli (MPEs) on short-term outcome.

      Design

      A prospective registry of consecutive patients.

      Setting

      An 11-bed closed medical ICU at a 860-bed community general hospital

      Patients

      Forty-seven patients with shock or hypotension due to MPE and central pulmonary thromboemboli detected by transesophageal echocardiography who were treated with thrombolysis between January 1994 and April 2000.

      Procedures

      Patients were divided into two groups according to the following characteristics of the detected thromboemboli: group 1, thrombi with one or more long, mobile parts; and group 2, immobile thrombi. Right heart catheterization was performed.

      Results

      The incidence of both types of thromboemboli was comparable. Groups 1 and 2 showed no differences in demographic data, risk factors for pulmonary embolism, length of preceding clinical symptoms, percentage of patients in shock, hemodynamic variables, serum lactate levels on hospital admission, and treatment. Seven fatal cases due to obstructive shock and right heart failure were present in group 2, but none were present in group 1 (7 of 23 patients vs 0 of 24 patients, respectively; p < 0.05). At 12 h, the cardiac index was lower in group 2 than in group 1 (2.6 ± 1.0 vs 3.1 ± 0.9 L/min/m2, respectively; p < 0.05), and the central venous pressure (15.0 ± 6.2 vs 12.5 ± 3.7 mm Hg, respectively; p < 0.05) and total pulmonary resistance (12.9 ± 5.9 vs 8.6 ± 2.7 mm Hg/L/min/m2, respectively; p < 0.001) were higher in group 2 compared to group 1. On hospital admission, inclusion in group 2 (p < 0.03; hazard ratio, 9.53; 95% confidence interval [CI], 1.19 to 76.47) and preexisting chronic medical or neurologic disease (p < 0.01; hazard ratio, 16.4; 95% CI, 1.97 to 136.3) were independent predictors of 30-day mortality.

      Conclusion

      On hospital admission, morphology of the thromboemboli and the presence of pre-existing chronic medical or neurologic disease are independent predictors of 30-day mortality. Patients with immobile central pulmonary thromboemboli have a worse short-term outcome than those with mobile central pulmonary thromboemboli.

      Key words

      Abbreviations:

      CI (confidence interval), CVP (central venous pressure), MPAP (mean pulmonary artery pressure), MPE (massive pulmonary embolism), PE (pulmonary embolism), rt-PA (recombinant human tissue plasminogen activator), SK (streptokinase), TEE (transesophageal echocardiography), TPR (total pulmonary resistance), UK (urokinase)
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