In Reply: Managing right ventricular failure in the setting of pulmonary embolism

Sharmeen Sorathia; Anibelky Almanzar; Abhishek Bhandiwad; Phoo Pwint Nandar

doi:10.3949/ccjm.92c.07004

We sincerely appreciate the thoughtful observations provided by Dr. Katyal and Dr. Joshi. Their insights contribute meaningfully to the ongoing discussion regarding the management of right ventricular failure in the setting of pulmonary embolism (PE). Please find our point-by-point responses below.

We agree that serum lactate is a valuable marker of tissue hypoperfusion and low cardiac output, and we routinely incorporate it into clinical decision-making in real-world practice. Its prognostic significance is well supported by the literature, and its role in risk stratification continues to evolve.

While we acknowledge the recommendations favoring low-molecular-weight heparin, in clinical practice unfractionated heparin is often selected in anticipation of potential interventions like catheter-directed thrombolysis or thrombectomy, given its shorter half-life and reversibility, which offer procedural flexibility.

Syncope can occur in the context of massive or submassive PE due to abrupt right ventricular outflow obstruction, leading to a sudden drop in left ventricular preload and systemic cardiac output. This pathophysiologic cascade may result in transient loss of consciousness from sudden hypotension or hypoperfusion.

We fully agree that patients with high-risk PE are not a homogeneous group. The spectrum of high-risk PE is diverse, and tailored therapeutic approaches, including low-dose thrombolysis in select stable patients, represent a reasonable and evolving strategy supported by emerging evidence.

Regarding dobutamine as an inotrope for hemodynamic support, given the heterogeneity of hemodynamic profiles in PE, we concur that the choice between inotropes and vasopressors should be individualized. Vasopressin may indeed offer hemodynamic benefits in certain patients, and a case-by-case assessment is essential.

In conclusion, we are grateful for these thoughtful comments that highlight the complexity of PE management and the importance of ongoing dialogue. These nuanced clinical scenarios underscore the value of a multidisciplinary approach through a Pulmonary Embolism Response Team, allowing for collaborative decision-making across specialties.