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 Outcomes of saddle pulmonary embolism: a nested case-control study

The management of saddle PE is controversial. There is a diversity of opinions and practices, with no apparent consensus for treatment. A previous case series suggested that patients diagnosed with saddle PE need aggressive therapy, such as surgical embolectomy, owing to an increased risk of mortality. However, other contemporary studies have suggested that saddle PE is not associated with worse short-term clinical outcomes. In conclusion, our results suggest that patients with saddle PE do not have a worse 30-day prognosis than patients with proximal PE matched by age, sex, systolic blood pressure, and the presence of cancer. In the absence of hypotension, it is difficult to justify aggressive therapy such as thrombolysis or surgical embolectomy in this group of patients.

 Saddle pulmonary embolism: Is it as bad as it looks? A community hospital experience

. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

 Saddling up

A saddle PE carries with it the potential for catastrophe, as it is a large clot burden that can result in sudden obstructive shock and death. PE is classified based on the hemodynamic effect, rather than the size. It is important to make the distinction between stable and unstable, as patients that are unstable are more likely to die from obstructive shock. In our patient, he was hemodynamically stable, no evidence for right heart strain, leading to the patient being treated with intravenous heparin. Treatment options beyond traditional therapy like heparin includes thrombolysis and localized catheter director therapy. The current consensus among the literature indicates that patients with a confirmed PE or multiple emboli complicated by severe RV dysfunction and hemodynamic instability secondary to an acute massive PE should receive thrombolysis.

Articles of Interest

A Patient With a Large Pulmonary Saddle Embolus Eluding Both Clinical Gestalt and Validated Decision Rules

We report a patient with chest pain who was classified as having low risk for pulmonary embolism with clinical gestalt and accepted clinical decision rules. An inadvertently ordered D-dimer and abnormal result, however, led to the identification of a large saddle embolus. This case illustrates the fallibility of even well-validated decision aids and that an embolism missed by these tools is not necessarily low risk or indicative of a low clot burden.

A rare case report of a saddle pulmonary embolism presenting with high grade fevers, responsive to anticoagulation

It is imperative to include pulmonary embolism in the differential diagnosis, when presented with high-grade fever in patients with unclear diagnosis.

Massive Life-Threatening Saddle Pulmonary Embolism in a Healthy 28-Year-Old

Saddle pulmonary emboli are a type of venous thromboembolism located at the bifurcation of the pulmonary artery with the potential to cause cardiogenic shock and death. These conditions call for urgent treatment via a catheter-driven thrombectomy or thrombolysis. The clotting and transit process is quick; therefore, immediate action is necessary. However, diagnosis and treatment can often get delayed due to the potential asymptomatic presentation.

Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.

Saddle Pulmonary Embolism: Is It the Same as 'Massive' PE?

One thing this study brings out, though, is the distinction between SPE and massive pulmonary embolism (MPE). MPE is a clinical syndrome with high mortality defined by the degree of hemodynamic compromise present in a patient with acute PE essentially, cardiogenic shock or persistent hypotension, further specified as a systolic blood pressure persistently < 90 mmHg, or a drop in baseline blood pressure of at least 40 mmHg for > 15 minutes. SPE is very common among patients with MPE, but the reverse is not necessarily the case.

Saddle Pulmonary Embolus Successfully Treated With Unfractionated Heparin

Patients with massive saddle pulmonary embolus may present without haemodynamic compromise, respiratory distress or obvious RV pressure overload. Systemic anticoagulation using intravenous UFH followed by oral warfarin therapy with repeat imaging to monitor the status of the thrombus, remains a reasonable treatment strategy for such patients.

Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics

Saddle PE may account for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with tachycardia and tachypnea, have more frequent elevations of cardiac troponins, and require more frequent ICU admissions and thrombolysis than those with non-saddle PE. They have also higher rates of RV enlargement and dysfunction. More importantly, patients with saddle PE tend to have higher rates of late decompensation and cardiac arrest after their initial presentation.

Submassive Central Saddle and Extensive Bilateral Pulmonary Embolism Presenting as Syncope Treated with Catheter-directed Therapy

Massive and submassive pulmonary emboli (PE) are rare but potentially life-threatening medical conditions that necessitate immediate recognition and appropriate treatment. We report a 52-year-old man who was found to have a submassive central saddle and extensive bilateral PEs after experiencing a syncopal event and who had evidence of right heart strain and pulmonary hypertension. He was subsequently treated with catheter-assisted thrombectomy and pulmonary artery tissue plasminogen activator administration.

Resources

Radiopaedia

Saddle pulmonary embolism commonly refers to a large pulmonary embolism that straddles the bifurcation of the pulmonary trunk, extending into the left and right pulmonary arteries. If large enough, it can completely obstruct both left and right pulmonary arteries resulting in right heart failure and, unless treatment is prompt, death. With such extensive embolic burden, signs of right heart strain are usually present...