1. Pulmonary embolism and methods of treatment Nizhny Novgorod state medical Academy Department of Hospital Surgery Medvedev A.P. Sobolev Y.A.

2. Annually 0,1% of population die from venous thromboembolic complications in the world

3. Statistics 1. Cohen A.T. et al. 2007 2. Heit J.A. et al. 2005 And 3 million deaths in the world. Nearly 300,000 deaths in USA. (2) Pulmonary embolism causes more than 500,000 deaths in Europe (1)

4. 1. Dobesh P.P. Pharmacotherapy, 2009 2. House of Commons Health Committee Second Report of Session 2004-2005 Every year more than 640 million £ is spent in the UK (2) In the USA the economic losses from VTEC are $ 1.5 billion $ per year (1) Expenditures

5. Acute pulmonary embolism: the myths and misconceptions.  …the massive PE always leads to the death of the patient…  …if the patient has survived, it means that he's had an embolism of peripheral branches of PA…  …patients with pulmonary embolism of peripheral branches of PA do not need any specialized assistance…

6. Defenition: Pulmonary thromboembolism – is a sudden obstruction of the branches of the pulmonary artery by thromboemboli, initially formed in the veins of the systemic circulation or in the right heart which is the greatest threat in the development of pulmonary hypertension and failure of the right ventricle, which is observed in occlusion over 50% of the arterial channel.

7. Etiology: Sources of emboli: The SVC system – 0,4% Right heart – 10,4% The IVC system – 84,5% Sources of emboli: The SVC system – 0,4% Right heart – 10,4% The IVC system – 84,5% Localization emboli: Smaller branches – 27,1% Equity and segmental– 17,1% Trunk and main branches– 55,8% Localization emboli: Smaller branches – 27,1% Equity and segmental– 17,1% Trunk and main branches– 55,8% * Embolism of segmental and equity branches causes death in only 6.4% of patients. * Embolism of main PA and major branches causes fulminant death in 61,3% of patients

8. Mortality risk at acute PE Risk factors Clinical (shock or hypotension) RV dysfunction Myocardial damage High risk >15% ++* Intermediate risk 3-15% –+ + –+ – + Low risk <1% ––– * is not necessary to confirm RV dysfunction to determination high-risk of death if the shock or hypotension is present. Mortality risk stratification in acute pulmonary embolism. Guidelines on the diagnosis and management of acute pulmonary embolism (2008)

9. Clinical types of pulmonary embolism Acute (12,8%) Acute start, chest pain, breathlessness, hypotension, acute heart failure. Subacute (31,4%) Progressive lung and heart failure, pneumonia, cough with bloody sputum. Reccurent (41,8%) Reccurent episodes of breathlessness, syncope, pneumonia.

10. Aims of diagnostic : To confirm the presence of pulmonary embolism. To identify the localization and lesion area. To estimate the severity of hemodynamic disorders To determine the source of embolization

11. Сlinical presentation Pulmonary and pleural syndrome *Breathlessness *Cyanosis of the face and the upper half of the body *Chest pain *Cough with bloody sputum Cardiac syndrome *Angina *Tachycardia *Hypotension Cerebral syndrome *Syncope *Hemiplegia (V.S. Saveliev, E.G. Yablokov, A.I. Kirienko, 1979)

12. DIAGNOSTICSDIAGNOSTICS Echo : Allows us to detect the thromboemboli in the pulmonary artery and determine the severity of pulmonary hypertension. ECG: acute RBBB, overload of RA MSCT: determination of localization of tromboemboli X-ray Expansion of the roots of the lungs decrease of pulmonary pattern Pathological pulmonary shadows (atelectasis) Pleurisy High standing of the diaphragm Cardiac Cath : «Amputation» syndrome of branches of the pulmonary artery Manometry (35-80 mm Hg) Scintigraphy- violation of lung perfusion

13. Dysfunction of the right ventricle in acute pulmonary embolism Overstrain signs of the right ventricle. Dilatation of the right ventricle EDV >30 mm Hypokinesis of free wall of the right ventricle The velocity of tricuspid regurgitation in systole >2,6 м/с

14. Victor Savelyev – a Russian pioneer in diagnostics, treatment and prophylaxis of pulmonary embolism

15. *Normalization of hemodynamics *Restoration of pulmonary arteries *Recurrency prevention Treatment objectives : I. Ohotin

16. Aims of treatment of PE 1.Removing threat of death from acute heart failure 2.Improvement of lung perfusion and prevention of chronic pulmonary hypertension 3.Recurrency prevention

17. Treatment choice ? ? 1. Pharmacological embolectomy (thrombolytic therapy) 2. Open embolectomy 3. Endovascular embolectomy

18. Types of localization of emboli in PE 5- year Pressure in PAsurvival rate < 30 90 % 31 - 40 50 % 41 - 50 35 % > 50 10 %

19. Thrombolysis Thrombolytic therapy leads to a fast recovery of the occluded pulmonary artery, reducing pulmonary hypertension and overstrain of the right ventricle. The indication for therapy with thrombolytics is the development of acute massive pulmonary embolism with symptoms of arterial hypotension, or shock. Thrombolytic therapy is associated with increased risk of bleeding.

20. Modes of thrombolytic therapy in acute pulmonary embolism Modes of thrombolytic therapy in acute pulmonary embolism Streptokinase 250 000 IU as a loading dose over 30 minutes, then 100 000 IU/h for 12-24 hours Boost mode: 1500000 IU for 2 hours. Urokinase 4400 IU/kg as a loading dose over 10 minutes, then 4400 IU/kg/h in 12-24 hours Boost mode: 3000000 IU for 2 hours. Alteplaza 10 mg intravenous bolus, then 90 mg for 2 hours, or 0.6 mg/kg for 15 minutes (maximum dose of 50 mg)

21. Shock phase - acute condition, with severe disturbances of hemodynamics (clinically apparent); The period of relative compensation of the right ventricle; The acute deterioration in hemodynamics, due to decompensation of the right ventricle. Surgical treatment in these cases is accompanied by high mortality «Wait for death to operate???»

22. TLT with "open eyes"  We support the accelerated mode of conducting TLT for dynamic control of pressure in the pulmonary artery.  TLT is effective if there is a progressive reduction of pressure in the pulmonary artery.

23. THROMBOLYTIC THERAPY HELPS: THROMBOLYTIC THERAPY HELPS:  Lysis of thromboemboli (86%);  To increase the effectiveness of antishock therapy;  To increase the period of relative compensation function of the right heart;  To improve the peripheral blood flow in the pulmonary artery;  To restore the patency of the veins of systemic circulation and recurrency prevention of pulmonary embolism.

24. Contraindications to thrombolytic therapy Absolute contraindications: Hemorrhagic stroke or stroke of unknown character Ischemic stroke for the last 6 months A tumor of the central nervous system Trauma or surgery (for 3 weeks) Recent gastrointestinal bleeding (last month) Bleeding of unknown genesis Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.

25. Contraindications to thrombolytic therapy Relative contraindications: Transient ischemic attack for the last 6 months Taking oral anticoagulants Pregnancy or the postpartum period for 1 month Puncture vessels with impossibility compression Injury in consequence after resuscitation Refractory hypertension Systolic blood pressure of more than 180 mm Hg Infectious endocarditis Active peptic ulcer Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.

26. Residual pulmonary hypertension more than 30 mm Hg requires: MSCT or APG central occlusion is indication to surgery (open or endovascular) in other variants - pharmacotherapy (under the control of the pulm.pressure) Basic therapy (cardiac glycosides, diuretics, anticoagulants Phlebotonic) Specific drugs (Sildenofil, Vasaprostan Ventavis)

27. Indications for surgery ( in inefficiency or inability TLT) 1. The pressure in the pulmonary artery > 50 mm Hg with a shock, progressive dysfunction of RV and severe arterial hypoxemia; 2. The existence of intracardiac tromboemboli; 3. Central or "mixed" localization of emboli in the pulmonary arteries.

28. Patiens 81 patients with subtotal obstruction of the main pulmonary artery or it΄s main branches were operated: 41 male, and 40 female patients; Mean age – 39,52 (from 17 to 83) years; In all cases, pulmonary embolism (PE) was determined as massive.

29. The algorithm of surgical treatment Ppulm > 50 Central 2- sided defeat APG, MSCT Open embolectomy in the specialized clinic

30. The algorithm of surgical treatment Ppulm > 50 APG, MSCT Central and peripheral defeat Open embolectomy with retrograde perfusion

31. Results Positive echocardiography dynamics to the third day of the postoperative period before the operation after the operation

32. Finding the source of embolization ultrasound duplex scanning

33. It is impossible to predict which of patients will develop recurrence of PE. You can prevent thrombotic complications by using adequate preventive measures.

34. The duration of prophylaxis of thrombosis Diagnosis The duration of anticoagulant prophylaxis Trauma, surgery  3 months(shin)  3 months (shin)  6 months (hip) Idiopathic thrombosis 6 months Relapsing course of disease Hereditary thrombophilia, implantation cava-filter Lifelong therapy Oncology Oncology To eliminate the causes of the disease

35. Conclusions TLT increases the efficiency of antishock therapy, prolongs the period of relative compensation function of the right heart, improves peripheral blood in the pulmonary arteries and prevents recurrence of pulmonary embolism

36. Conclusions In 50% of cases TLT is a radical method of treatment of pulmonary embolism. And only when it is not efficient or when there are contraindications an open embolectomy is needed to be performed.

37. Conclusions Surgical treatment is an effective method of correction of PE and its complications. Which leads to a complete regression of cardio-pulmonary pathology.

38. Thank you for attention ! Thank you for attention !