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Vol. 69. Issue 8.
Pages 801-802 (August 2016)
Letter to the Editor
DOI: 10.1016/j.rec.2016.05.005
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Systemic Thrombolysis for High-risk Pulmonary Embolism Versus Percutaneous Transcatheter Treatment. Response
Trombolisis sistémica de la embolia pulmonar de alto riesgo frente al tratamiento percutáneo. Respuesta
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Angel Sánchez-Recalde
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Recalde@secardiologia.es

Corresponding author:
, Raúl Moreno, Santiago Jiménez-Valero, Guillermo Galeote
Departamento de Cardiología Intervencionista, Hospital Universitario La Paz, Madrid, Spain
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Rev Esp Cardiol. 2016;69:800-110.1016/j.rec.2016.04.025
Francisco Ramón Pampín-Huerta, Dolores Moreira-Gómez, Verónica Rodríguez-López, María del Pilar Madruga-Garrido
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To the Editor,

We read the letter by Pampín-Huerta et al regarding our article1 with interest. According to the existing evidence, systemic thrombolysis is the treatment of choice for massive pulmonary embolism (PE). Our series included patients with an absolute contraindication and, under these circumstances, the guidelines recommend 2 alternative options: surgical or percutaneous embolectomy, depending on the experience and facilities in each center. Given that the means for surgical treatment are seldom available, even in our center, which is a major hospital in Madrid, Spain, a percutaneous intervention was performed.

Although there are no absolute contraindications for thrombolysis in critical situations, routine clinical practice demonstrates the opposite to be true. In fact more than 60% of the patients with massive PE do not receive this treatment,2 perhaps because the risk of major bleeding is over 20%, including the 3% risk of intracranial bleeding, and increases exponentially in those patients who are most unstable.3 Thus, although the evidence on transcatheter treatment is limited, at the present time, it is the only valid alternative in patients with massive PE in whom thrombolysis is contraindicated or who are at high risk for bleeding.

Common sense tells us, and different registries demonstrate,4 that 1 fourth or 1 fifth of the in situ systemic dose in the thrombus is associated with a minor bleeding risk; this, added to the fact that the percutaneous approach enables the fragmentation and aspiration of the thrombus, may prove to be vital in cases of central PE.

At the present time, it is unusual for a single physician to assess the indication and decide on the systemic thrombolysis dose in a case of intermediate- to high-risk PE. The current trend in final decision-making concerning thrombolytic, percutaneous, or surgical treatment involves urgent consensus on the part of a multidisciplinary team in which an interventional cardiologist or radiologist plays an important role.5,6

CONFLICTS OF INTEREST

A. Sánchez-Recalde is Associate Editor of Revista Española de Cardiología.

References
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A. Sánchez-Recalde, R. Moreno, B. Estébanez-Flores, S. Jiménez-Valero, de Lorenzo García, A. Mateos, et al.
Tratamiento percutáneo de la tromboembolia pulmonar aguda masiva.
Rev Esp Cardiol., 69 (2016), pp. 340-342
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N. Kucher, E. Rossi, M. de Rosa, S.Z. Goldhaber.
Massive pulmonary embolism.
Circulation., 113 (2006), pp. 577-582
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K. Fiumara, N. Kucher, J. Fanikos, S.Z. Goldhaber.
Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism.
Am J Cardiol., 97 (2006), pp. 127-129
[4]
W.T. Kuo, A. Banerjee, P.S. Kim, F.J. DeMarco, J.R. Levy, K. Unver, et al.
Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry.
Chest., 148 (2015), pp. 667-673
[5]
W.A. Jaber, P.P. Fong, G. Weisz, O. Lattouf, J. Jenkins, K. Rosenfield, et al.
Acute pulmonary embolism with an emphasis on an interventional approach.
J Am Coll Cardiol., 67 (2016), pp. 991-1002
[6]
Grupo de Trabajo de la SEC para la guía de la ESC 2014 sobre el diagnóstico y tratamiento de la embolia pulmonar aguda, revisores expertos para la guía de la ESC 2014 sobre el diagnóstico y tratamiento de la embolia pulmonar aguda, Comité de Guías de la SEC.
Comentarios a la guía de práctica clínica de la ESC 2014 sobre el diagnóstico y tratamiento de la embolia pulmonar aguda.
Rev Esp Cardiol., 68 (2015), pp. 10-16
Copyright © 2016. Sociedad Española de Cardiología
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