Title Opterećenje desnog srca u plućnom embolizmu Title (english) Right ventricle in acute pulmonary embolism Author Bea Hohšteter Mentor Gordana Pavliša (mentor)Committee member Sanja Popović-Grle (predsjednik povjerenstva)Committee member Marko Jakopović (član povjerenstva)Committee member Gordana Pavliša (član povjerenstva)Granter University of Zagreb Defense date and country 2020-07-17, Croatia Scientific / art field, BIOMEDICINE AND HEALTHCARE Abstract Plućna embolija (PE) je česta i ozbiljna manifestacija venskog tromboembolizma (VTE). Osim što kompromitira respiratornu funkciju, PE može dovesti do akutnog zatajenja desnog srca što je najčešći uzrok smrtnosti. Rana terapijska intervencija je stoga nužna, no nespecifičnost i individualnost kliničke prezentacije PE otežavaju brzo prepoznavanje uzroka. Cirkulatorna (ne)stabilnost presudni je čimbenik u postupanju s bolesnikom. U stabilnih osoba, proces teče od preddijagnostičke procjene vjerojatnosti za plućnu emboliju (PE) i svrstavanja bolesnika u kategorije niske, umjerene ili visoke vjerojatnosti za PE, određivanja vrijednosti D-dimera (u bolesnika niske i srednje vjerojatnosti) do konačne potvrde PE nekom od slikovnih dijagnostičkih metoda (najčeše kompjuterizirana tomgrafska plućna angiografija, CTPA). U osoba srednje ili visoke vjerojatnosti za PE, inicijalna antikoagulantna terapija primjenjuje se bez čekanja konačne potvrde PE, a pri niskoj vjerojatnosti, nakon sigurne potvrde dijagnoze. U svih bolesnika s PE, ključna je procjena srčane funkcije određivanjem serumske razine troponina, transtorakalnom ehokardiografijom (TTE) ili CTPA-om jer je opterećenje desnog srca glavni rizični faktor u PE. U bolesnika niskog rizika, srčana je funkcija očuvana i nakon uvođenja antikoagulantne terapije, izgledna je mogućnost njihovog otpusta na kućno liječenje. Osobe u kojih postoje znakovi srčanog opterećenja, a nisu hemodinamski ugrožene, pripadaju kategoriji intermedijarnog rizika. Uz antikoagulanse, kod njih je potrebno daljnje bolničko praćenje jer se potencijalni budući hemodinamski kolaps ne može isključiti. Hemodinamski ugroženi bolesnici zahtjevaju hitnu cirkulatornu i respiratornu potporu, procjenu stanja srca TTE-om ili hitni CTPA, primjenu antikoagulantne terapije i što raniju reperfuzijsku terapiju koja će se konačno razriješiti njihovo stanje. Ekstrakorporalna membranska oksigenacija (ECMO) kao terapija premoštenja do reperfuzije, doprinosi povoljnijem kliničkom ishodu. Sistemska tromboliza i kirurška embolektomija radikalne su terapijske opcije i rezervirane su za hemodinamski nestabilne bolesnike. Endovaskularna intervencija nosi značajno manji rizik od ozbiljne hemoragije nego sistemska tromboliza i daleko je manje invazivna nego konvencionalni kirurški zahvat zbog čega bi se, osim u bolesnika visokog rizika, mogla koristiti i u nekih bolesnika intermedijarnog rizika. Točno propisanih indikacija nema i za bolesnike srednjeg rizika ovaj postupak nije u rutinskoj primjeni. Osim inicijalne antikoagulantne terapije, potrebna je i dugoročnija primjena antikoagulansa nakon PE incidenta. Točna duljina primjene antikoagulansa ovisi o prisutnosti rizičnih faktora za VTE i individualnim komorbiditetima bolesnika i u nekim ju je slučajevima teško precizno definirati.
Abstract (english) Pulmonary embolism (PE) is a frequent and serious manifestation of venous thromboembolism (VTE). Alongside impairment in gas exchange, PE might also cause acute right heart failure, which is the most common cause of death in PE. Therefore, early therapeutic intervention is crucial, but signs and symptoms in PE are not specific and further testing is required in order to confirm diagnosis. First and central parameter which indicates further approach is hemodynamic (in)stability. If there are no signs of circulatory compromise, the next step is to determine the likelihood of PE by using pre-
diagnostic tests which sort patients into categories of high, intermediate or low probability for PE. In low and intermediate category, D-dimers should be measured prior to imaging. In most cases, CTPA (computed tomographic pulmonary angiography) will supply final confirmation of the disease existence. Initial anticoagulant treatment is administered before final confirmation of diagnosis for high- or intermediate- likelihood category. Evaluation of cardiac function by measuring troponin levels, transthoracic echocardiogram (TTE) or CTPA is crucial in all patients with PE. Signs of cardiac strain are essential parameter in PE risk assessment. In low risk-PE, any sign of cardiac compromise is absent and those patients are often discharged after administration and prescription of anticoagulant treatment. In intermediate-risk PE, signs of right heart strain are present, possibility of future hemodynamic collapse cannot be excluded and those patients require further monitoring, next to anticoagulants. If hemodynamic compromise is present, emergency cardiac and respiratory support,
heart assessment by TTE or urgent CTPA, anticoagulant treatment and reperfusion therapy should be provided as soon as
possible. If patient remains unstable despite the supportive treatment, extracorporeal membrane oxygenation (ECMO) may be used as a bridge to reperfusion therapy. Systemic thrombolysis and surgical embolectomy are aggressive treatment options, reserved for patients with hemodynamic compromise. Catheter directed thrombolysis is far less invasive then surgical treatment and risk of serious hemorrhage is much lower compared to systemic thrombolysis. For those reasons, it might be helpful in some intermediate- risk patients with significant heart strain. Exact guidelines that would clearly indicate which intermediate-risk patients should be treated by this method are not yet available and this procedure is not routinely used. Following initial anticoagulant treatment, long-term anticoagulation is prescribed after PE incident. Exact duration of this treatment depends on the risk factors for VTE and patient's individual comorbidities and remains difficult to determine in a number of cases.
Keywords
antikoagulantna terpija
ECMO
hemodinamski kolaps
disfunkcija desnog srca
plućni embolizam
reperfuzijska terapija
Keywords (english)
anticoagulant treatment
ECMO
hemodynamic compromise
pulmonary embolism
reperfusion treatment
right heart failure
Language croatian URN:NBN urn:nbn:hr:105:381973 Study programme Title: Medicine Type of resource Text File origin Born digital Access conditions Open access Terms of use Created on 2021-03-08 10:38:45
