Mechanical Thrombectomy Improves Cardiac Index in Pulmonary Embolism Patients in Subclinical Shock
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Cardiovascular, Pulmonary, 2022
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INTRODUCTION/HYPOTHESIS: Most pulmonary embolism (PE) patients are normotensive, and PE risk stratification schemes have limitations in identifying the subset of these normotensive patients who are at risk for sudden decompensation. Even if patients present as hemodynamically stable, they may be in subclinical shock due to low cardiac index (CI). The objective of this research is to assess immediate changes in CI in risk-stratified PE patients undergoing percutaneous mechanical thrombectomy as frontline therapy. METHODS: PE patients were enrolled in FLASH, a prospective registry evaluating the safety and effectiveness of mechanical thrombectomy with the FlowTriever System (Inari Medical, Irvine, CA; NCT03761173). Patients were risk-stratified using current ESC guidelines, simplified Pulmonary Embolism Severity Index (sPESI), and Bova score. Immediately prior to and following thrombectomy, CI was measured via right heart catheterization. At baseline, patients were grouped into low-CI (< 2 l/min/m2) and normal-CI (≥ 2 l/min/m2) cohorts, and the prevalence of patients with low CI was determined for each risk category. Pre- vs. post-thrombectomy changes in CI were then compared within the low-CI and normal-CI cohorts. RESULTS: Despite being in lower risk categories, 20% of patients with ESC intermediate-risk classification, 22% of patients with sPESI = 0, and 20% of patients with Stage I or II Bova scores had low CI at baseline. Among all patients in the low-CI cohort, CI increased significantly on-table after thrombectomy by an average of 13.3% from 1.7±0.2 to 1.9±0.4 l/min/m2 (p=0.005; Nf42). Patients who already had normal CI at baseline did not experience a significant change in CI (2.9±0.9 vs. 3.0±1.9 l/min/m2, p=0.207; Nf160). CONCLUSIONS: Regardless of the specific risk stratification scheme used, approximately one-fifth of all patients in the lower-risk tiers within each scheme had low CI at baseline. These patients experienced a significant on-table improvement in CI immediately following mechanical thrombectomy, with the average post-treatment CI almost reaching physiologically normal levels. These data suggest that a substantial proportion of hemodynamically stable PE patients may be in subclinical shock, and these same patients may realize an immediate improvement in CI following mechanical thrombectomy.
Meta Tag
Content Type Presentation
Knowledge Area Cardiovascular
Knowledge Area Pulmonary
Knowledge Level Intermediate
Knowledge Level Advanced
Learning Pathway Cardiothoracic Critical Care
Membership Level Select
Tag Shock
Tag Pulmonary Embolism
Tag Hemodynamic Monitoring
Tag Pulmonary Circulation
Tag Thromboembolism
Tag Cardiothoracic Critical Care
Year 2022
mechanical thrombectomy
cardiac index
pulmonary embolism
risk stratification
subclinical shock


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