CONGRESS ABSTRACT

A 73-year-old male presented to the emergency department with a 1-week history of asthenia and exertional dyspnoea. He reported a recent finding of a not yet characterized renal mass in a not relevant past medical history. At the admission, he was haemodynamically stable. Electrocardiogram showed sinus rhythm without relevant abnormalities. Blood results evidenced only a slight  increase of hs-troponin levels and D-dimer. An early point-of-care ultrasound (POCUS) demonstrated normal chambers dimensions and biventricular function but in the right atrium an elongated and mobile mass was documented. The echo-features were very suggestive of a large thrombus and a computed tomography pulmonary angiogram revealed several emboli in the left pulmonary artery. At the admission to our cardiac intensive care unit, according to pulmonary embolism (PE) ESC guidelines1, systemic anticoagulation was started with an aPTT-guided unfractioned heparin (UFH) infusion. Intensive monitoring was set to permit early detection of haemodynamic impairment. Multidisciplinary discussion on management was instituted but, soon after, the patient had a PEA arrest. POCUS demonstrated an extremely dilated right ventricle so rescue fibrinolytic therapy (FT) was attempted during cardiopulmonary resuscitation but the patient died. The intermediate–high-risk profile of PE encompasses a very heterogeneous group of patients, in whom controversy still exists regarding the net clinical benefit of using FT compared to anticoagulation alone. In the largest PEIHTO trial, FT compared to UFH alone prevented death and hemodynamic decompensation but increased major bleedings and strokes2. Data meta-analysis confirmed that in these patients, FT was associated with a lower mortality at the cost of more bleedings3. Current guidelines endorse FT only at the moment of clinical deterioration.  Nevertheless, stable patients with “thrombus in transit” represent a niche of potentially rapidly deteriorating clinical scenario with not-predictable timing. In this setting we believe that, waiting for data deriving from interventional approaches, an aggressive therapeutical strategy should be considered, offering more liberally an early FT, especially when absolute contraindications are lacking. Data from registry or trials are strongly requested. 1.Konstantinides SV et al. EHJ 2020;41:543-603. 2.Meyer G et al. NEJM 2014;370:1402-11. 3.Chatterjee et al. JAMA 2014;311:2414-21.