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.


      A prospective registry of consecutive patients.


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


      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.


      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.


      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.


      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


      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)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Nixdorff U
        • Erbel R
        • Drexler M
        • et al.
        Detection of thromboembolus of right pulmonary artery by transesophageal two-dimensional echocardiography.
        Am J Cardiol. 1988; 61: 488-489
        • Krivec B
        • Voga G
        • Zuran I
        • et al.
        Diagnosis and treatment of shock due to massive pulmonary embolism.
        Chest. 1997; 112: 1310-1316
        • Morgenstern E
        • Korell U
        • Richter J
        Platelets and fibrin strands during clot retraction.
        Thromb Res. 1984; 33: 617-623
        • O‘Shaughnessy AM
        • Fitzgerald DE
        Determining the stage of organisation and natural history of thrombosis using computer analysis.
        Int Angiol. 2000; 19: 220-227
        • Sabovic M
        • Lijnen HR
        • Keber D
        • et al.
        Correlation between progressive adsorption of plasminogen to blood clots and their sensitivity to lysis.
        Thromb Haemost. 1990; 64: 450-454
        • Wittlich N
        • Erbel R
        • Eichler A
        • et al.
        Detection of central pulmonary thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism.
        J Am Soc Echocardiogr. 1992; 5: 515-524
        • PIOPED Investigators
        Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism (PIOPED).
        JAMA. 1990; 263: 2753-2759
        • Chan RK
        • Johns JA
        • Calafiore P
        Clinical implications of the morphological features of central pulmonary artery thromboemboli shown by transoesophageal echocardiography.
        Br Heart J. 1994; 72: 58-62
        • Lin PH
        • Chen C
        • Sourowiec SM
        • et al.
        Evaluation of thrombolysis in a porcine model of chronic deep venous thrombosis: an endovascular model.
        J Vasc Surg. 2001; 33: 621-627
        • Konstantinides S
        • Geibel A
        • Olschewski M
        • et al.
        Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism.
        Circulation. 1997; 96: 882-888
        • Michard F
        • Meyer G
        • Wysocki M
        • et al.
        Cardiorespiratory efficacy of thrombolytic therapy in acute massive pulmonary embolism: identification of predictive factors.
        Eur Respir J. 1999; 13: 610-615
        • McCotter CJ
        • Chiang KS
        • Fearrington EL
        Intrapulmonary artery infusion of urokinase for treatment of massive pulmonary embolism: a review of 26 patients with and without contraindications to systemic thrombolytic therapy.
        Clin Cardiol. 1999; 22: 661-664
        • Dalen JE
        • Alpert JS
        • Hirsch J
        Thrombolytic therapy for pulmonary embolism: is it effective? Is it safe?—when is it indicated?.
        Arch Intern Med. 1997; 157: 2550-2556
        • Meyer G
        • Sors H
        • Charbonnier B
        • et al.
        Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute pulmonary embolism: a European multicenter double-blind trial; the European Cooperative Study Group for Pulmonary Embolism.
        J Am Coll Cardiol. 1992; 19: 239-245
        • Blinc A
        • Francis CW
        Transport processes in fibrinolysis and fibrinolytic therapy.
        Thromb Haemost. 1996; 76: 481-491
        • Prewitt RM
        Principles of thrombolysis in pulmonary embolism.
        Chest. 1991; 99: 157S-164S
        • Goldhaber SZ
        • Hennekens CH
        • Evans DA
        • et al.
        Factors associated with correct antemortem diagnosis of major pulmonary embolism.
        Am J Med. 1982; 73: 822-826
        • Caprini JA
        • Arcelus JI
        • Hoffman KN
        • et al.
        Venous duplex imaging follow-up of acute symptomatic deep vein thrombosis of the leg.
        J Vasc Surg. 1995; 21: 472-476
        • O‘Shaughnessy AM
        • Fitzgerald DE
        Natural history of proximal deep vein thrombosis assessed by duplex ultrasound.
        Int Angiol. 1997; 16: 45-49
        • Leeper Jr, KV
        • Popovich Jr, J
        • Lesser BA
        • et al.
        Treatment of massive acute pulmonary embolism: the use of low dose of intrapulmonary artery streptokinase combined with full doses of systemic heparin.
        Chest. 1988; 93: 234-240
        • Verstraete M
        • Miller GA
        • Bounameaux H
        • et al.
        Intravenous and intrapulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism.
        Circulation. 1988; 77: 353-360
        • Russo A
        • DeLuca M
        • Vigna C
        • et al.
        Central pulmonary artery lesions in chronic obstructive pulmonary disease.
        Circulation. 1999; 100: 1808-1815
        • Summers RM
        • Andrasko-Bourgeois J
        • Feuerstein IM
        • et al.
        Evaluation of aortic root by MRI: insights from patients with homozygous familial hypercholesterolemia.
        Circulation. 1998; 98: 509-518
        • Kasper W
        • Konstantinides S
        • Geibel A
        • et al.
        Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.
        J Am Coll Cardiol. 1997; 30: 1165-1171
        • Carson JL
        • Kelley MA
        • Duff A
        • et al.
        The clinical course of pulmonary embolism in a hospital population: one-year follow-up of PIOPED patients.
        N Engl J Med. 1992; 326: 1240-1245
        • Meneveau N
        • Schiele F
        • Metz D
        • et al.
        Comparative efficacy of two-hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: immediate clinical and hemodynamic outcome and one-year follow-up.
        J Am Coll Cardiol. 1998; 31: 1057-1063
        • Mercat A
        • Diehl J-L
        • Meyer G
        • et al.
        Hemodynamic effects of fluid loading in acute massive pulmonary embolism.
        Crit Care Med. 1999; 27: 540-544
        • Podbregar M
        • Voga G
        • Krivec B
        • et al.
        Should we confirm our clinical diagnostic certainty by autopsies?.
        Intensive Care Med. 2001; 27: 1750-1755