Current problems in cardiology · 2026
Management of pulmonary arterial hypertension with intermediate-high-risk pulmonary embolism during pregnancy: Diagnostic challenges, catheter-directed thrombolysis, and intravenous treprostinil - A narrative review with an institutional case snapshot.
СтатьяКлинический случайОбзорНазвание и аннотация: Перевод пока не подготовлен
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García-Cesar Marisol, Cueto-Robledo Guillermo, Roldan-Valadez Ernesto, Torres-Rojas María-Berenice, Navarro-Vergara Dulce-Iliana, Ruiz-Domínguez Daniel, Hernandez-Villa Lizbeth
Аннотация
BACKGROUND: Maternal mortality from pregnancy-related pulmonary arterial hypertension (PAH) is estimated at 7-12%. The superimposition of pulmonary embolism (PE) and COVID-19 further compromises right-ventricular (RV) function. Pregnancy-compatible PAH pharmacotherapy and catheter-directed techniques show promise; however, their intersection remains undocumented.
METHODS: We performed a narrative review of imaging diagnosis, risk stratification, catheter-directed reperfusion, PAH-targeted pharmacotherapy, and multidisciplinary peripartum management of PAH complicated by acute PE during pregnancy. MEDLINE/PubMed, Embase, Scopus, and the Cochrane Library were searched up to March 2026. We also describe an institutional case from the Hospital General de México Dr. Eduardo Liceaga (Mexico City, Mexico).
RESULTS: Evidence supports echocardiography for initial assessment, CT pulmonary angiography for embolic/vascular evaluation, right-heart catheterization for hemodynamic determination, and catheter-directed thrombolysis for intermediate-high-risk PE when systemic thrombolysis is contraindicated. The institutional case describes a 17-year-old primigravida (24.6 weeks' gestation) with undiagnosed idiopathic PAH (mean pulmonary artery pressure 64 mmHg; pulmonary vascular resistance (PVR) 13.8 Wood units), intermediate-high-risk PE (thrombotic burden 37.5%), and COVID-19 pneumonia. Catheter-directed thrombolysis combined with sildenafil and intravenous treprostinil achieved substantial hemodynamic improvement (cardiac index 2.8 to 4.2 L/min/m²; PVR 13.8 to 6.7 Wood units). Elective cesarean at 37 weeks resulted in satisfactory maternal and neonatal outcomes.
CONCLUSIONS: Early, multidisciplinary approaches integrating invasive hemodynamics, catheter-directed thrombolysis, and pregnancy-compatible PAH therapy can decompress RV function and allow safe pregnancy continuation. Prospective international registries and pregnancy-specific PERT pathways are urgently needed.
METHODS: We performed a narrative review of imaging diagnosis, risk stratification, catheter-directed reperfusion, PAH-targeted pharmacotherapy, and multidisciplinary peripartum management of PAH complicated by acute PE during pregnancy. MEDLINE/PubMed, Embase, Scopus, and the Cochrane Library were searched up to March 2026. We also describe an institutional case from the Hospital General de México Dr. Eduardo Liceaga (Mexico City, Mexico).
RESULTS: Evidence supports echocardiography for initial assessment, CT pulmonary angiography for embolic/vascular evaluation, right-heart catheterization for hemodynamic determination, and catheter-directed thrombolysis for intermediate-high-risk PE when systemic thrombolysis is contraindicated. The institutional case describes a 17-year-old primigravida (24.6 weeks' gestation) with undiagnosed idiopathic PAH (mean pulmonary artery pressure 64 mmHg; pulmonary vascular resistance (PVR) 13.8 Wood units), intermediate-high-risk PE (thrombotic burden 37.5%), and COVID-19 pneumonia. Catheter-directed thrombolysis combined with sildenafil and intravenous treprostinil achieved substantial hemodynamic improvement (cardiac index 2.8 to 4.2 L/min/m²; PVR 13.8 to 6.7 Wood units). Elective cesarean at 37 weeks resulted in satisfactory maternal and neonatal outcomes.
CONCLUSIONS: Early, multidisciplinary approaches integrating invasive hemodynamics, catheter-directed thrombolysis, and pregnancy-compatible PAH therapy can decompress RV function and allow safe pregnancy continuation. Prospective international registries and pregnancy-specific PERT pathways are urgently needed.