Repeat systemic thrombolysis with a second 100 mg dose of alteplase improved oxygen saturation from 65% to 92% and recovered right ventricular function without major bleeding in a massive PE patient.
Case Report (n=1)
Does repeat systemic thrombolysis improve hemodynamics and right ventricular function in a patient with massive pulmonary embolism unresponsive to initial fibrinolysis?
Repeat systemic thrombolysis may be a feasible and potentially lifesaving rescue option for massive pulmonary embolism unresponsive to initial fibrinolysis, particularly when other reperfusion strategies are unavailable.
Massive pulmonary embolism (PE) is a life-threatening emergency with high mortality. Systemic thrombolysis is the standard reperfusion therapy for patients with hemodynamic instability. However, when initial thrombolysis fails, therapeutic options are limited and evidence supporting subsequent interventions is scarce. We describe a 45-year-old man with hyperlipidemia and depression who presented with dyspnea, hypoxemia, and cardiogenic shock. Echocardiography revealed right ventricular dilatation and dysfunction, consistent with massive PE. Initial therapy with full-dose alteplase (100 mg) and anticoagulation achieved only transient hemodynamic stabilization. The patient remained severely hypoxemic with persistent right ventricle (RV) dysfunction. As catheter-directed therapy and surgical embolectomy were unavailable, repeat systemic thrombolysis was pursued. A second full dose of alteplase (100 mg) was administered on hospital day four. Within 24 h, oxygen saturation improved from 65% to 92% on room air, and echocardiography confirmed substantial recovery of RV size and function. No major bleeding or other complications occurred during hospitalization. Current guidelines do not recommend repeat thrombolysis for massive PE unresponsive to initial fibrinolysis, and available evidence is confined to case reports. This case demonstrates that, in carefully selected patients without contraindications, repeat systemic thrombolysis may represent a feasible and potentially lifesaving rescue option, particularly in resource-limited settings where other reperfusion strategies are not available. Further studies are needed to define safety, patient selection, and long-term outcomes.
Hoseini et al. (Mon,) conducted a case report in Massive pulmonary embolism (n=1). Repeat systemic thrombolysis (alteplase) was evaluated on Oxygen saturation and right ventricular function. Repeat systemic thrombolysis with a second 100 mg dose of alteplase improved oxygen saturation from 65% to 92% and recovered right ventricular function without major bleeding in a massive PE patient.