Letter to the Editor

Managing right ventricular failure in the setting of pulmonary embolism

Anup Katyal, MD and Ashwani Joshi, MD
Cleveland Clinic Journal of Medicine July 2025, 92 (7) 396; DOI: https://doi.org/10.3949/ccjm.92c.07003

To the Editor: We would like to make several observations regarding the review article by Dr. Sorathia and colleagues1 on managing right ventricular failure in patients with pulmonary embolism (PE) published in the May issue.

Lactate measurement, which is a marker of tissue perfusion, should be incorporated in risk stratification of PE. In one study, arterial lactate 2 mmol/L or greater in normotensive patients was associated with a 30-day mortality of 16.4%.2 Higher lactate correlated with higher mortality. In another study, venous lactate greater than 3.3 mmol/L predicted adverse outcome and mortality in normotensive patients with PE.3

The authors mention unfractionated heparin as an anticoagulant used in management of high-risk PE. Low-molecular-weight heparin should be the initial anticoagulant in hospitalized patients based on expert opinion, given the lack of therapeutic concentration levels with unfractionated heparin in the first 48 hours after initiation.4

We are unaware of syncope as a sign of high-risk PE, as mentioned by the authors.

Patients with high-risk PE are not a homogeneous group. High-risk PE can be further classified into stable, unstable, and catastrophic. In select patients with stable high-risk PE (norepinephrine ≤ 0.25 μg/kg/min), peripheral tissue plasminogen activator 25 mg administered over 6 hours may be an attractive option when one is reluctant to use full-dose thrombolytics.5

The authors mention dobutamine as an inotrope for hemodynamic support. Vasopressin, with its unique properties of increasing systemic blood pressure without increasing pulmonary vascular resistance, may be a better option given hypotension risk due to vasodilatation with dobutamine.

With a multitude of ongoing randomized controlled trials, including the Pulmonary Embolism International Thrombolysis (PEITHO)-3, Higher-Risk Pulmonary Embolism Thrombolysis (HI-PEITHO), Pulmonary Embolism: Thrombus Removal With Catheter-Directed Therapy (PE-TRACT), and RCT of FlowTriever vs Anticoagulation Alone in Pulmonary Embolism (PEERLESS 2) studies, more data about the short- and long-term safety and efficacy of catheter-directed thrombolysis, catheter-directed thrombectomy, and low-dose systemic thrombolysis will be forthcoming. The profound disease burden of acute PE mandates thoughtful consideration of how these therapies are used.

REFERENCES

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    1. Sorathia S,
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    4. Nandar PP
    . Managing right ventricular failure in the setting of pulmonary embolism. Cleve Clin J Med 2025; 92(5):301–309. doi:10.3949/ccjm.92a.24069
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    1. Aykan AÇ,
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