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Management of massive and submassive pulmonary embolism: focus on recent randomized trials

Sanchez, Oliviera,b,c,d; Planquette, Benjamina,b,c; Meyer, Guya,b,c,d

Current Opinion in Pulmonary Medicine: September 2014 - Volume 20 - Issue 5 - p 393–399
doi: 10.1097/MCP.0000000000000089
DISORDERS OF THE PULMONARY CIRCULATION: Edited by Richard N. Channick and Marc Humbert

Purpose of review: Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review.

Recent findings: The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results.

Summary: Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.

aUniversité Paris Descartes, Paris Sorbonne Cité

bAssistance Publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Pneumologie et Soins Intensifs

cINSERM UMR 970

dGIRC Thrombose, Paris, France

Correspondence to Olivier Sanchez, Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France. Tel: +33 1 56 09 34 61; fax: +33 1 56 09 32 55; e-mail: olivier.sanchez@egp.aphp.fr

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins