Valerio Luca, Klok Frederikus A, Barco Stefano
Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstraße 1, Building 403, 55131 Mainz, Germany.
Eur Heart J Suppl. 2019 Nov;21(Suppl I):I1-I13. doi: 10.1093/eurheartj/suz222. Epub 2019 Nov 21.
Haemodynamic instability and right ventricular dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). Residual thrombi and persistent right ventricular dysfunction may contribute to post-PE functional impairment, and influence the risk of developing chronic thromboembolic pulmonary hypertension. Patients with haemodynamic instability at presentation (high-risk PE) require immediate primary reperfusion to relieve the obstruction in the pulmonary circulation and increase the chances of survival. Surgical removal of the thrombi or catheter-directed reperfusion strategies is alternatives in patients with contraindications to systemic thrombolysis. For haemodynamically stable patients with signs of right ventricular overload or dysfunction (intermediate-risk PE), systemic standard-dose thrombolysis is currently not recommended, because the risk of major bleeding associated with the treatment outweighs its benefits. In such cases, thrombolysis should be considered only as a rescue intervention if haemodynamic decompensation develops. Catheter-directed pharmaco-logical and pharmaco-mechanical techniques ensure swift recovery of echocardiographic and haemodynamic parameters and may be characterized by better safety profile than systemic thrombolysis. For survivors of acute PE, little is known on the effects of reperfusion therapies on the risk of chronic functional and haemodynamic impairment. In intermediate-risk PE patients, available data suggest that systemic thrombolysis may have little impact on long-term symptoms and functional limitation, echocardiographic parameters, and occurrence of chronic thromboembolic pulmonary hypertension. Ongoing and future interventional studies will clarify whether 'safer' reperfusion strategies may improve early clinical outcomes without increasing the risk of bleeding and contribute to reducing the burden of long-term complications after intermediate-risk PE.
血流动力学不稳定和右心室功能障碍是急性肺栓塞（PE）患者短期预后的关键决定因素。残留血栓和持续性右心室功能障碍可能导致PE后功能受损，并影响慢性血栓栓塞性肺动脉高压的发生风险。就诊时存在血流动力学不稳定的患者（高危PE）需要立即进行初始再灌注，以解除肺循环梗阻并增加生存机会。对于有全身溶栓禁忌证的患者，手术取栓或导管定向再灌注策略是替代方案。对于血流动力学稳定但有右心室负荷过重或功能障碍体征的患者（中危PE），目前不推荐全身标准剂量溶栓，因为与该治疗相关的大出血风险超过了其益处。在这种情况下，只有在出现血流动力学失代偿时才应考虑将溶栓作为一种挽救性干预措施。导管定向药物和药物机械技术可确保超声心动图和血流动力学参数迅速恢复，其安全性可能优于全身溶栓。对于急性PE幸存者，关于再灌注治疗对慢性功能和血流动力学损害风险的影响知之甚少。在中危PE患者中，现有数据表明全身溶栓可能对长期症状、功能受限、超声心动图参数以及慢性血栓栓塞性肺动脉高压的发生影响不大。正在进行和未来的干预性研究将阐明“更安全”的再灌注策略是否可在不增加出血风险的情况下改善早期临床结局，并有助于减轻中危PE后长期并发症的负担。
