Response to ‘Alternatives to thrombolysis in submassive saddle pulmonary embolism’

Dear Editor, We are thankful for the opportunity to respond to Dr. Jolobe’s letter titled ‘Alternatives to thrombolysis in submassive saddle pulmonary embolism’. Dr. Jolobe commented upon our image titled ‘Pulmonary saddle thrombus’.1 The optimum treatment strategy for PE patients with right ventricular dysfunction and normal blood pressure has been a topic of debate.2 We agree that there is an increased risk of major bleeding (including intracranial bleed) when systemic thrombolytic therapy is used for patients with pulmonary embolism (PE). There is a definite need for the management strategies that can effectively tackle such patients without increasing the bleeding risk. However, the patients belonging to this ‘intermediate’ risk category may have heterogeneous outcome. Therefore, the need to consider the option of systemic thrombolysis should be individualized. The index patient had systolic blood pressure > 90 mmHg at presentation but during the course of evaluation he had clinical deterioration in the form of tachycardia (pulse rate 144 bpm) and worsening of hypoxemia (arterial PaO2 < 60 mmHg) that required oxygen supplementation. In addition, he was found to have DVT involving both lower limbs and RV enlargement on echocardiography. In view of clinical deterioration and presence of factors that put this patient in high risk category [Pulmonary Embolism Severity Index (PESI) class V (152 points); sPESI score = 3], the decision for thrombolysis was contemplated. Systolic blood pressure < 100 mmHg has been identified as adverse prognostic factor by PESI and Geneva clinical scores.3,4 In contrast to developed world, the management of PE patients in emergency rooms of developing countries is challenging because of huge patient load, delayed confirmation of diagnosis and lack of monitoring equipment. Therefore, the practicality of recommendations given in guidelines may not always be possible in resource constraint settings.5 Dr Jolobe also discussed the role of new modalities–rheolytic thrombectomy and ultrasound assisted catheter-directed thrombolysis––for massive as well as submassive PE.6,7 These modalities shall be particularly useful in hemodynamically unstable PE patients who are at high risk of bleeding (where systemic thrombolysis cannot be used) or in cases where systemic thrombolysis is not successful. The availability of requisite equipment and local expertise shall be crucial factors in wider applicability of such treatment modalities. Conflict of interest: None declared.