title: Management of massive and submassive pulmonary embolism: focus on recent randomized trials.
abstract: OBJECTIVE
  Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review.
  
  
  RESULTS
  The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results.
  
  
  CONCLUSIONS
  Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
authors.affiliation: aUniversité Paris Descartes, Paris Sorbonne Cité bAssistance Publique - Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Pneumologie et Soins Intensifs cINSERM UMR 970 dGIRC Thrombose, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Sanchez
authors.forename: Benjamin
authors.initials: B
authors.lastname: Planquette
authors.forename: Guy
authors.initials: G
authors.lastname: Meyer
mesh_terms: D017128:Embolectomy; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D011655:Pulmonary Embolism / Q000188:drug therapy* / Q000503:physiopathology; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D018497:Ventricular Dysfunction, Right
chemical_list: D005343:Fibrinolytic Agents