Criteria for massive pulmonary emboli (recent pulmonary emboli plus one or more of the following):
(1) cardiogenic shock with systolic blood pressure <= 90 mm Hg associated with clinical signs of organ hypoperfusion and hypoxia
(2) syncope
(3) pulmonary vascular obstruction > 50%
(4) mean pulmonary artery pressure > 20 mm Hg by right heart catheterization and at least one of the following echocardiographic findings for right ventricular dysfunction:
(4a) right ventricular to left ventricular end-diastolic diameter ratio >= 1 in the 4-chamber view
(4b) paradoxical septal systolic motion
(4c) pulmonary hypertension (defined as right ventricular to left atrial gradient > 30 mm Hg)
Time frame from for evaluating the response to thrombolytic therapy: first 36 hours
Criteria for failed thrombolytic therapy - both of the following:
(1) persistent clinical instability (>= 2 of the following)
(1a) refractory cardiogenic shock
(1b) systemic arterial hypotension with systolic blood pressure <= 90 mm Hg OR a pressure drop >= 40 mm Hg for > 15 minutes not due to sepsis, hypovolemia or new-onset arrhythmia
(1c) severe hypoxemia (PaO2 <= 55 mm Hg on room air or oxygen saturation <=90% on room air)
(1d) tachycardia with heart rate >= 110 beats per minute
(2) residual echocardiographic right ventricular dysfunction (persistence of >= 2 initial right ventricular dysfunction criteria)
where:
• I assume that criteria 1a consists of 1b plus 1c and organ dysfunction. Criteria 1a alone may be sufficient to demonstrate persistent clinical instability.
Rescue surgical embolectomy was the recommended therapy for these patients. A patient at a hospital without thoracic surgery should be transferred to a center that does.
