Acute pulmonary embolism (PE) bears a significant burden on health and survival. Rapid and accurate risk stratification and management are of paramount importance to ensure the highest quality of care. This present article summarizes currently available and emerging management strategies for the disease. The authors not only review current evidence regarding early therapy of acute PE, including supportive care, anticoagulation, thrombolysis, surgical and catheter-based treatment, but also the possible role of mechanical circulatory support in PE. The authors also discuss complications related to PE and its management.

2nd Department of Medicine Department of Cardiovascular Medicine General University Hospital and 1st Faculty of Medicine Charles University Prague Prague Czech Republic

Zobrazit více v PubMed

Grignone M, Girling L, Prewitt RM. Volume expansion versus norepinephrine in treatment of a low cardiac output complicating an acute increase in right ventricular afterload in dogs. Anesthesiology. 1984;60:132–5. PubMed

Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H. Hemodynamic effects of fluid loading in acute massive pulmonary embolism. Crit Care Med. 1999;27:540–4. PubMed

Gromadziński L, Ciurzyński M, Januszko-Giergielewicz B, et al. Diagnostic value of mitral and tricuspid annular excursion in the diagnostics of acute pulmonary embolism patients with chronic heart failure. Int J Cardiol. 2011;149:118–9. PubMed

Widimský J, Malý J, Eliáš P, et al. Doporučení pro diagnostiku a léčbu akutní plicní embolie. Vnitř. Lék. 2008;54:1S25–1S72.

Torbicki A, Perrier A, Konstantidines S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2008;29:2276–315. PubMed

Manier G, Castaing Y. Influence of cardiac output on oxygen exchange in acute pulmonary embolism. Am Rev Respir Dis. 1992;145:130–6. PubMed

Prewitt RM. Hemodynamic management in pulmonary embolism and acute hypoxemic respiratory failure. Crit Care Med. 1990;18:S61–S69. PubMed

Layish DT, Tapson VF. Pharmacologic hemodynamic support in massive pulmonary embolism. Chest. 1997;111:218–24. PubMed

Büller HR, Davidson BL, Decousus H, et al. Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med. 2003;349:1695–702. (Erratum in: N Engl J Med 2004;350:423). PubMed

Mehta SR, Granger CB, Eikelboom JW, et al. Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Results from the OASIS-5 trial. J Am Coll Cardiol. 2007;50:1742–51. PubMed

Bailen M, Cuadra J, Aguayo H. Thrombolysis during cardiopulmonary resuscitation in fulminant pulmonary embolism: A review. Crit Care Med. 2001;29:2211–2219. PubMed

Nolan JP, Soarb J, Zidemanc, et al. on behalf of the ERC Guidelines Writing Group European Resuscitation Council Guidelines for Resuscitation 2010. Section 1. Executive summary. Resuscitation. 2010;81:1219–76. PubMed

Bottiger B, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: A prospective clinical trial. Lancet. 2001;357:1583–5. PubMed

Fatovich D, Dobb G, Cluqston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial) Resuscitation. 2004;61:309–13. PubMed

Bottiger W, Arntz HR, Chamberlain DA, et al. for the TROICA Trial Investigators and the European Resuscitation Council Study Group Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest. Bernd International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: The Thrombolysis in Cardiac Arrest (TROICA) Study. N Engl J Med. 2008;359:2651–62. PubMed

Prusczyk P, Torbicki A, Kuch-Wocial A, et al. Diagnostic value of transesophageal echocardiography in suspected haemodynamically significant pulmonary embolism. Heart. 2001;85:628–34. PubMed PMC

Jerjes-Sanchez C, Ramirez-Rivera A, de Lourdes Garcia M, et al. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: A randomized controlled trial. J Thromb Thrombolysis. 1995;2:227–9. PubMed

Capstick T, Henry MT. Efficacy of thrombolytic agents in the treatment of pulmonary embolism. Eur Respir J. 2005;26:864–74. PubMed

Stein P, Henry J. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995;108:978–81. PubMed

Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) Lancet. 1999;353:1386–9. PubMed

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;30:1165–71. PubMed

Dalla-Volta S, Palla A, Santolicandro A, et al. PAIMS 2: Alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. J Am Coll Cardiol. 1992;20:520–6. PubMed

Goldhaber S, Haire W, Feldstein M, et al. Alteplase versus heparin in acute pulmonary embolism: Randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993;341:507–11. PubMed

Konstantinides S, Tiede N, Geibel A, et al. Comparison of alteplase Versus heparin for resolution of major pulmonary embolism. Am J Cardiol. 1998;82:966–70. PubMed

Ribeiro A, Lindmarker P, Johnsson H, et al. Pulmonary embolism: One-year follow-up with echocardiography doppler and five-year survival analysis. Circulation. 1999;99:1325–30. PubMed

Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pumonary embolism. N Engl J Med. 2002;347:1143. PubMed

Tissue plasminogen activator for the treatment of acute pulmonary embolism: A collaborative study by the PIOPED Investigators. Chest. 1990;97:528–33. PubMed

Wan S, Quinlan D, Agnelli G, et al. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: A meta-analysis of the randomized controlled trials. Circulation. 2004;110:744–9. PubMed

Steering Committee Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: Rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Am Heart J. 2012;163:33–8. PubMed

Torbicky A, Galie N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: Results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41:2245–52. PubMed

Chapoutot L, Nazeyrollas P, Metz D, et al. Floating right heart thrombi and pulmonary embolism: Diagnosis, outcome and therapeutic management. Cardiology. 1996;87:169–74. PubMed

Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: Delayed disappearance after thrombolytic treatment. Chest. 2005;127:1051–3. PubMed

Farfel Z, Shechter M, Vered Z, et al. Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. Am Heart J. 1987;113:171–8. PubMed

Justin P, Pierard L. Management of mobile right heart thrombi: A prospective series. Int J Card. 2005;99:381–8. PubMed

Schuchlenz H, Weihs W, Horner S, et al. The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events. Am J Med. 2000;109:456–62. PubMed

Konstantinides S, Geibel A, Kasper W, et al. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998;97:1946–51. PubMed

Meneveau N, Schiele F, Metz D, et al. Comparative efficacy of a two-hour regimen of streptokinase versus alteplase in acute pulmonary embolism: Immediate clinical and hemodynamic outcome and one-year follow-up. J Am Coll Cardiol. 1998;31:1057–63. PubMed

Wang CH, Zhai Z, Yang Y, et al. for the China Venous Thromboembolism (VTE) study group Half the dosage, similar efficacy, less bleeding. The new tissue plasminogen activator regimen for pulmonary embolism? Chest. 2010;136:254–64. PubMed

Meneveau N, Seronde MF, Blonde MC, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest. 2006;129:1043–50. PubMed

Yalamanchili K, Fleisher AG, Lehrman SG, et al. Open pulmonary embolectomy for treatment of major pulmonary embolism. Ann Thorac Surg. 2004;77:819–23. PubMed

Leacche M, Unic D, Goldhaber SZ, et al. Modern surgical treatment of massive pulmonary embolism: Results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg. 2005;129:1018–23. PubMed

Kuo WT, Gould MK, Louie JD, et al. Catheter-directed therapy for the treatment of massive pulmonary embolism: Systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 2009;20:1431–40. PubMed

Widimský J. Diagnostika a léčba akutní plicní embolie v roce 2010. Vnitřní lékařství. 2011;57:5–21. PubMed

Aigner C, Wisser W, Taghavi S, et al. Institutional experience with extracorporeal membrane oxygenation in lung transplantation. Eur J Cardiothorac Surg. 2007;31:468–73. discussion 473–4. PubMed

Berman M, Tsui S, Vuylsteke A, et al. Successful extracorporeal membrane oxygenation after pulmonary thromboendarterectony. Ann Thorac Surg. 2008;86:1261–7. PubMed

Kawahito K, Murata S, Adachi H, et al. Resuscitation and circulatory support using extracorporeal membrane oxygenation for fulminant pulmonary embolism. Artif Organs. 2000;24:427–30. PubMed

Misawa Y, Fuse K, Yamaguchi T, et al. Mechanical circulatory assist for pulmonary embolism. Perfusion. 2000;15:527–9. PubMed

Gregoric ID, Chandra D, Myers TJ, et al. Extracorporeal membrane oxygenation as a bridge to emergency heart-lung transplantation in a patient with idiopathic pulmonary arterial hypertension. J Heart Lung Transplant. 2008;27:466–8. PubMed

Bělohlávek J, Rohn V, Jansa P, et al. Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern. J Invasive Cardiol. 2010;22:365–9. PubMed

Berman M, Tsui S, Vuylsteke A, et al. Life-threatening right ventricular failure in pulmonary hypertension: RVAD or ECMO? J Heart Lung Transplant. 2008;27:1188–9. PubMed

Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism