Advanced Management of Intermediate- and High-Risk Pulmonary Embolism: JACC Focus Seminar

Abstract

Intermediate-risk (submassive) pulmonary embolism (PE) describes normotensive patients with evidence of right ventricular compromise, whereas high-risk (massive) PE comprises those who have experienced hemodynamic decompensation with hypotension, cardiogenic shock, or cardiac arrest. Together, these 2 syndromes represent the most clinically challenging manifestations of the PE spectrum. Prompt therapeutic anticoagulation remains the cornerstone of therapy for both intermediate- and high-risk PE. Patients with intermediate-risk PE who subsequently deteriorate despite anticoagulation and those with high-risk PE require additional advanced therapies, typically focused on pulmonary artery reperfusion. Strategies for reperfusion therapy include systemic fibrinolysis, surgical pulmonary embolectomy, and a growing number of options for catheter-based therapy. Multidisciplinary PE response teams can aid in selection of appropriate management strategies, especially where gaps in evidence exist and guideline recommendations are sparse.

Keywords: IVC filter; anticoagulation; catheter thrombolysis; catheter-directed therapy; fibrinolysis; mechanical circulatory support; pulmonary embolism; right ventricular failure; surgical embolectomy; thrombolysis.