Sustained improvement of pulmonary hemodynamics in patients at rest and during exercise after thrombolytic treatment of massive pulmonary embolism

Abstract

This study assessed the long-term effects of thrombolytic treatment in patients with acute massive pulmonary embolism (PE). Seven patients with PE that followed deep-vein thrombosis underwent pulmonary angiography and pressure measurements before and 6 ± 3 days (mean ± SD) and 15 ± 4 months after treatment with intrapulmonary infusions of urokinase (average dose 1724 U/kg·hr) and heparin (average dose 17 U/kg·hr). Treatment was guided by daily measurements of pulmonary arterial (PA) pressure and was continued until PA pressure had normalized (average of 6 days). Late after treatment patients returned for pulmonary angiographic examination, right heart catheterization at rest and during bicycle exercise, and phlebography of the deep veins of both legs. Pulmonary angiograms showed massive obstruction before therapy (Walsh index 15 ± 2 points of a maximum of 18 points), which was improved 6 days (3 ± 3 points) and 15 months (1 ± 2 points) after therapy. Mean PA pressure declined from 37 ± 9 to 13 ± 3 mm Hg after 6 days and to 15 ± 3 mm Hg after 15 months. No recurrence of PE was observed. In six of seven patients at rest and during bicycle exercise (up to 100 W) in the supine position mean PA pressure and total pulmonary resistance remained within normal limits. Over the short term all patients showed clinical signs of deep-vein thrombosis; 15 months later four patients had normal deep veins, but three patients had still phlebographic signs of old thrombosis. Thus, after thrombolytic treatment of acute massive PE normal pulmonary arteriograms were obtained in six of seven patients studied; furthermore, the reserve capacity of the pulmonary vasculature as assessed during heavy exercise was normal in these patients.