Clinical Analysis Of Saddle Pulmonary Embolism In A Double Center And A Cohort Study With Pulmonary Embolism In The Left Or Right Trunk

ObjectiveSaddle pulmonary embolism (SPE) defined as the pulmonary embolism straddling the pulmonary bifurcation and obstruction of right and left pulmonary artery trunk. Because of its large thrombus burden effect on hemodynamics and the thrombus was unstable, it was generally considered that the prognosis was not good, and it need to be more aggressive treatment, such as thrombolysis or surgical embolectomy. But recent studies suggest that the prognosis of patients with SPE is not poor. We analyzed the data of patients with SPE and cohort study with non-SPE to evaluate clinical characteristics of SPE for improving recognition and treatment of SPE.Methods1. Retrospective review of 17 patients with saddle pulmonary thromboembolism from August 2011 to February 2015. Their clinical manifestations, laboratory data, imaging features, therapy and prognosis were analyzed.2. A cohort study was performed in 17 patients with saddle pulmonary thromboembolism (saddle group) and 96 patients with pulmonary embolism in right and/or left pulmonary artery trunk(non-saddle group).3. One patient with pulmonary artery sarcoma confirmed by the final pathologic diagnosis of pulmonary artery embolism was analyzed.Results1. Two hospitals by CT pulmonary angiography (CTPA) and/or radionuclide pulmonary ventilation/perfusion (V/Q) scan confirmed pulmonary embolism in 423 cases, of which 17 cases of patients with saddle pulmonary thromboembolism, accounting for 4%.There were 4 females and 13 males with a mean age of(60±15) years. Most common presenting symptoms included dyspnea in 12 cases and cough in 6 cases、chest pain in 5 cases、syncope in 5 cases.There were 2 patients with shock or hypotension. The patient’s heart rate (93±22) beats/min(bpm), the heart rate≥110bpm in 5 cases,and 5 cases had extremity swelling, and 4 of them had unilateral lower extremity edema.9 cases had right ventricular dysfunction diagnosis by cardiac color Doppler ultrasound.2 cases were high-risk pulmonary embolism,2 cases were intermediate-high pulmonary embolism.All patients were managed in the hospital,4 patients received thrombolytic therapy and 12 patients received anticoagulant therapy,1 patient gave up anticoagulant therapy due to gastrointestinal bleeding.All the patients survived during their hospitalization.17 patients were in 3-43 months follow-up,median time 16 months,there was one patient died in the 22 month after discharge.2. There were difference between the SPE and non-SPE in 3 months surgery or trauma and oxygen partial pressure, were 6 cases (35.3%) vs 9 cases (9.4%),P<0.01, and(89.27±25.21)mmHg vs (78.96±25.47)mmHg,P<0.05.Other clinical symptoms、 shock or hypotension、deep venous thrombosis、right ventricular dysfunction、risk stratification and treatment of pulmonary embolism were not statistically significant differences.The SPE group 3 months mortality was 0, and the non-SPE group with 2 cases of patients died, but no statistical difference(2.1% vs 0%, P> 0.05). Chronic thromboembolic pulmonary hypertension occurred in 2 patients of the SPE group, and non-SPE group 8 cases,no significant difference (11.8% vs 8.3%, P>0.05). Logistic regression analysis revealed that surgery or trauma and oxygen partial pressure were not the risk factors of the 30-day all-cause mortality.3. One case with saddle pulmonary artery sarcoma was confirmed by pathology and died at 16 months after the diagnosis.Conclusion1. Short term mortality in patients with saddle pulmonary thromboembolism is not high, and the patients can be treated according to the risk stratification of blood pressure, positive thrombolysis or surgical treatment is not required.2. Saddle pulmonary embolism patients should be wary of chronic thromboembolic pulmonary hypertension,and in acute saddle pulmonary thromboembolism also need to assess the risk of the disease,close follow-up.3. The pulmonary artery sarcoma may be considered if the effect of anti-thrombus treatment is not good in saddle pulmonary embolism patient.