Right ventricular systolic dysfunction in intermediate high-risk pulmonary embolism treated by ultrasound-assisted catheter-directed thrombolysis

For intermediate high-risk pulmonary embolism (PE), the 2014 ESC guidelines support the use of ultrasound-assisted catheter-directed thrombolysis (USAT). These devices provide an optimal balance between a rapid and efficient drug delivery to enable quick right ventricle relief while reducing the risk of bleedings compared to systemic thrombolysis. Some studies show the effect of this procedure on right ventricular (RV) dilatation but few talk about the systolic RV dysfunction, common and responsible for multiple hemodynamic complications. We aim to describe the real-life use and results of USAT procedure in our center compared to the reference treatment with unfractionated heparin alone (UFH). USAT was performed in eligible intermediate high-risk PE patients. Ineligible patients were treated with UFH. Primary outcome was the difference in RV systolic dysfunction (assessed by 3 parameters: visual evaluation with trans thoracic echocardiography (4 severity levels), Tricuspid Annulus Plane Systolic Exclusion (TAPSE) and maximal velocity of tricuspid annulus on tissue Doppler imaging (S’) from baseline to 24 hours. Between September 2017 and October 2018, 20 patients were selected for USAT procedure and 17 were treated with UFH. In the USAT group, 19 patients presented a RV systolic dysfunction at baseline. At 24 hours, only 9 patients presented a persistent RV systolic dysfunction, P = 0.0002. In the UFH group, 13 patients presented a RV systolic dysfunction at baseline and 11 at 24 hours, P = 0.089. The mean improvement in RV systolic function level from baseline to 24 hours was 1.4 ± 0.8 in the USAT group versus 0.29 ± 0.6 in the UFH group, P = 0.02. There was a trend in TAPSE and S’ in favor of the USAT group, P = 0.16 and P = 0.09 respectively. There was no significant bleeding event (Fig. 1). In this cohort, the USAT procedure seems to be efficient in improving the RV systolic function without increasing bleeding event.