Dynamic ambulatory evaluation of submassive pulmonary embolism increased a patient's PESI score from 44 to 104, prompting mechanical thrombectomy that reduced pulmonary pressure from 44 to 25 mmHg.
Does dynamic risk evaluation with ambulatory oximetry alter management in seemingly low-risk submassive pulmonary embolism?
Dynamic risk evaluation using ambulatory oximetry can unmask intermediate-risk features in seemingly low-risk submassive pulmonary embolism, guiding the decision for catheter-directed thrombectomy.
Tasa de eventos absoluta: 0% vs 0%
Introduction: Submassive pulmonary embolism is stratified with pulmonary embolism severity index (PESI) score, cardiac biomarkers, right ventricular (RV) strain, and proximity within the pulmonary artery. Our case demonstrates how the PESI score can evolve from rest to ambulation facilitating clinical decision making within a Pulmonary Embolism Response Team (PERT). Description: A 44-year-old female with no baseline medical history was hospitalized due to dyspnea out of proportion to simple tasks such as climbing the steps in her house and a near syncopal event while swimming (contradicting her active lifestyle). Initial workup demonstrated unprovoked, bilateral submassive pulmonary emboli extending within the left and right main pulmonary arteries (RV:LV >1 on CTA, likely originating from acute right peroneal DVT). Troponin peaked at 0.656 ng/mL with a normal pro-BNP. Transthoracic echo confirmed RV strain with moderate RV dilation, reduced RV systolic function, and markedly elevated estimated RVSP > 60 mmHg. Our PERT was split decision regarding invasive versus conservative therapy (PESI 44 (low risk) and resting oxygen >92% on room air). Heparin was continued for additional 24 hours and patient was further assessed with ambulatory oximetry. The 6-minute walk was prematurely stopped due to SpO2 of 81%, tachycardia, and tachypnea. PESI increased to 104 (intermediate risk) prompting shift to mechanical thrombectomy. Left pulmonary artery thrombectomy with TPA and aspiration was performed decreasing pressure from 44 to 25 mmHg. Treatment was transitioned to apixaban with disposition for hypercoagulability workup. Ambulatory oximetry was normal prior to discharge. Discussion: Our case highlights the importance of dynamic risk evaluation, especially in the setting of absent comorbidities, in seemingly initial low-risk submassive pulmonary emboli. Resting and ambulatory PESI scores could aid in the deciding between conservative and invasive management. Catheter directed thrombectomy facilitates immediate improvements in post operative central venous pressure, delta RV:LV ratio, and pulmonary artery systolic pressure. At follow up of 1.5 years, intermediate to high-risk submassive pulmonary emboli were more likely to have normalization of RV function compared to the standard anticoagulation group.
Gooden et al. (Sun,) reported a other. Dynamic ambulatory evaluation of submassive pulmonary embolism increased a patient's PESI score from 44 to 104, prompting mechanical thrombectomy that reduced pulmonary pressure from 44 to 25 mmHg.