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There are increasing treatment options for the management of acute pulmonary embolism (PE), though many are only available at tertiary care centers. Patients with acute pulmonary embolism with high-risk features are often transferred for consideration of such therapies. There are limited data describing outcomes in patients transferred with acute pulmonary embolism.We evaluated patients with acute pulmonary embolism at our tertiary care center from August 2012 through August 2018 and compared clinical characteristics, pulmonary embolism features, management, and outcomes in those transferred for acute pulmonary embolism to those that were not transferred.Of 2050 patients with pulmonary embolism included in the study, 432 (21.1%) were transferred from an outside hospital with a known diagnosis of pulmonary embolism. Patients transferred had a lower rate of malignancy (22.2% vs 33.3%; P.001) and median Charlson comorbidity index (3 vs 4; P.001). A higher percentage of patients transferred were classified as intermediate- or high-risk pulmonary embolism (62.5% vs 43.0%; P.001) and more frequently received advanced therapy beyond anticoagulation alone (12.5% vs 3.2%, P.001). Overall survival to discharge was similar between groups, though definite pulmonary embolism-related mortality was higher in the transferred group (38.5% vs 9.4%, P = .004).More than 1 in 5 patients treated for acute pulmonary embolism at a tertiary care center were transferred from an outside facility. Transferred patients had higher risk pulmonary embolism features, more often received advanced therapy, and had higher definite pulmonary embolism-related mortality. There are opportunities to further optimize outcomes of patients transferred for management of acute pulmonary embolism.

Pulmonary embolism (PE) response teams are the standard of care for the management of acute PE. The complications of PE extend far beyond the initial hospitalization period. In this study, we examined the role and potential benefits of dedicated pulmonary follow-up after hospital discharge for patients with PE.

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The direct-acting oral anticoagulants (DOACs) have been increasingly used over vitamin K antagonists in recent years because they do not require monitoring and have an immediate anticoagulation effect. In general, DOACs have exhibited a better safety profile and noninferiority for prophylaxis and treatment of venous thromboembolism (VTE) and stroke prevention in patients with atrial fibrillation compared with vitamin K antagonists in the non-ICU population; whether this finding holds true in patients who are critically ill remains unknown. The current review addresses the role of DOACs in special ICU populations, use of these agents for VTE prophylaxis, perioperative management of DOACs, drug monitoring, and potential drug interactions of DOACs in critically ill patients. Adverse events and available reversal agents for DOACs are also discussed.

Introduction Acute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients. Purpose of review The purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic. Recent findings There are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging. Summary Current use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.

Rationale: The novel coronavirus disease-19 (COVID-19) has presented major challenges for global health systems. Given limited availability of diagnostic testing and delays in test results during the first wave of the pandemic, our hospital used computed tomography (CT) to risk stratify patients with suspected COVID-19. The aim of this study was to describe the various patterns of disease on chest CT and relate them to chest x-ray (CXR) findings. Methods: This is a retrospective review of 559 symptomatic patients infected with COVID-19 (diagnosed by real-time reverse transcription polymerase chain reaction) admitted from March 2020 to May 2020 at Temple University Hospital (Philadelphia, PA) who received admission CXR and chest CT scans that were performed within 24 hours of admission. Scans were independently reviewed by a group of radiologists. CXRs was interpreted as “consistent with COVID-19” if there were lower lobe peripheral opacities. Chest CTs were evaluated for the presence of ground glass opacities, consolidations, interlobular septal thickening, centrilobular nodules, and crazy paving pattern. Chest CT was also assessed for background lung disease (emphysema, interstitial lung disease). Results: Of the 559 patients, median age was 58 years old, 55.5% were female, and 56.7% were African American. Median BMI was 31.61. Median duration of symptoms at time of chest imaging was 5 days. 153 (27.4%) of patient's admission CXR was not consistent with COVID-19. Of those, 124 (81%) had abnormalities on chest CT. Median number of lobes involved with disease on CT was 3.8 and 317 patients (56.7%) had all 5 lobes with disease. The most common abnormalities found were ground glass opacities (n=507, 90.7%), consolidations (n=224, 40%) and centrilobular nodules (n=127, 22.7%). Less common findings included pleural effusion (n=62, 11.8%), lymphadenopathy (n=55, 9.8%), pericardial effusion (n=24, 4.2%), and pneumothorax (n=3, 0.53%). Of note, 82 (14.7%) patients were found to have emphysema, and 2 (0.35%) were found to have interstitial lung disease. Conclusion: We present one of the largest reviews of CT scans in patients admitted for COVID-19. The majority of our population had significant burden of disease on CT at time of presentation. Ground glass opacities and consolidations were the predominant findings. Most patients did not have background emphysema or interstitial lung disease. The fact that many patients with normal CXR had abnormalities on chest CT highlights the utility of chest CT in evaluating patients with COVID-19.

Rationale: The novel coronavirus disease-19 (COVID-19) has overwhelmed global healthcare systems. It would be beneficial to identify clinical signs that predict adverse outcomes to anticipate clinical deterioration and optimize management. COVID-19 has presented with a variety of patterns on computed tomography (CT) and these findings may assist in disease stratification. This study aims to identify potential CT characteristics that may portend adverse outcomes. Methods: This is a retrospective review of 559 symptomatic patients infected with COVID-19 admitted from March 2020 to May 2020 at Temple University Hospital (Philadelphia, PA) who received thorax CT scans on admission. These scans were independently reviewed by a chest radiologist and evaluated for the presence of ground glass opacities, consolidations, interlobular septal thickening, enlarged pulmonary artery (PA) diameter, centrilobular nodules, and crazy paving pattern. Common CT findings were then associated with a combined adverse inpatient outcome (requiring high-flow oxygen, mechanical ventilation, and/or death) through univariate and multivariate logistic regression. Results: Of the 559 patients, 182 (32.6%) required high-flow oxygen, mechanical ventilation, and/or died. The cohort with adverse outcomes were older (mean age 65.0 years vs 56.7 years, p

Management includes ruling out alternate diagnoses, identifying occult/overt organ involvement, determining treatment, and recognizing worrisome features.

BACKGROUND The use of high-flow nasal therapy (HFNT) to treat COVID-19 pneumonia has been greatly debated around the world due to concerns about increased health care worker transmission and delays in invasive mechanical ventilation (IMV). Herein, we analyzed the utility of the noninvasive ROX (ratio of oxygen saturation) index to predict the need for and timing of IMV. OBJECTIVE This study aimed to assess whether the ROX index can be a useful score to predict intubation and IMV in patients receiving HFNT as treatment for COVID-19–related hypoxemic respiratory failure. METHODS This is a retrospective cohort analysis of 129 consecutive patients with COVID-19 admitted to Temple University Hospital in Philadelphia, PA, from March 10, 2020, to May 17, 2020. This is a single-center study conducted in designated COVID-19 units (intensive care unit and other wards) at Temple University Hospital. Patients with moderate and severe hypoxemic respiratory failure treated with HFNT were included in the study. HFNT patients were divided into two groups: HFNT only and intubation (ie, patients who progressed from HFNT to IMV). The primary outcome was the value of the ROX index in predicting the need for IMV. Secondary outcomes were mortality, rate of intubation, length of stay, and rate of nosocomial infections in a cohort treated initially with HFNT. RESULTS Of the 837 patients with COVID-19, 129 met the inclusion criteria. The mean age was 60.8 (SD 13.6) years, mean BMI was 32.6 (SD 8) kg/m², 58 (45%) were female, 72 (55.8%) were African American, 40 (31%) were Hispanic, and 48 (37.2%) were nonsmokers. The mean time to intubation was 2.5 (SD 3.3) days. An ROX index value of less than 5 at HFNT initiation was suggestive of progression to IMV (odds ratio [OR] 2.137, P=.052). Any further decrease in ROX index value after HFNT initiation was predictive of intubation (OR 14.67, PP CONCLUSIONS The ROX index helps decide which patients need IMV and may limit eventual morbidity and mortality associated with the progression to IMV.

Background Individual studies have reported widely variable rates for VTE and bleeding among hospitalized patients with coronavirus disease 2019 (COVID-19). Research Question What is the incidence of VTE and bleeding among hospitalized patients with COVID-19? Methods In this systematic review and meta-analysis, 15 standard sources and COVID-19-specific sources were searched between January 1, 2020, and July 31, 2020, with no restriction according to language. Incidence estimates were pooled by using random effects meta-analyses. Heterogeneity was evaluated by using the I2 statistic, and publication bias was assessed by using the Begg and Egger tests. Results The pooled incidence was 17.0% (95% CI, 13.4-20.9) for VTE, 12.1% (95% CI, 8.4-16.4) for DVT, 7.1% (95% CI, 5.3-9.1) for pulmonary embolism (PE), 7.8% (95% CI, 2.6-15.3) for bleeding, and 3.9% (95% CI, 1.2-7.9) for major bleeding. In subgroup meta-analyses, the incidence of VTE was higher when assessed according to screening (33.1% vs 9.8% by clinical diagnosis), among patients in the ICU (27.9% vs 7.1% in the ward), in prospective studies (25.5% vs 12.4% in retrospective studies), and with the inclusion of catheter-associated thrombosis/isolated distal DVTs and isolated subsegmental PEs. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate- or full-dose anticoagulation (21.4%) and the lowest in the only prospective study that assessed bleeding events (2.7%). Interpretation Among hospitalized patients with COVID-19, the overall estimated pooled incidence of VTE was 17.0%, with higher rates with routine screening, inclusion of distal DVT, and subsegmental PE, in critically ill patients and in prospective studies. Bleeding events were observed in 7.8% of patients and were sensitive to use of escalated doses of anticoagulants and nature of data collection. Additional studies are required to ascertain the significance of various thrombotic events and to identify strategies to improve patient outcomes. Trial Registry PROSPERO; No.: CRD42020198864; URL: https://www.crd.york.ac.uk/prospero/.

Objective Management of patients experiencing massive pulmonary embolism-related cardiac arrest is controversial. Venoarterial extracorporeal membranous oxygenation has emerged as a potential therapeutic option for these patients. We performed a systematic review assessing survival and predictors of mortality in patients with massive PE-related cardiac arrest with venoarterial extracorporeal membranous oxygenation use. Data sources A literature search was started on February 16, 2020, and completed on March 16, 2020, using PubMed, Embase, Cochrane Central, Cinahl, and Web of Science. Study selection We included all available literature that reported survival to discharge in patients managed with venoarterial extracorporeal membranous oxygenation for massive PE-related cardiac arrest. Data extraction We extracted patient characteristics, treatment details, and outcomes. Data synthesis About 301 patients were included in our systemic review from 77 selected articles (total screened, n = 1,115). About 183 out of 301 patients (61%) survived to discharge. Patients (n = 51) who received systemic thrombolysis prior to cannulation had similar survival compared with patients who did not (67% vs 61%, respectively; p = 0.48). There was no significant difference in risk of death if PE was the primary reason for admission or not (odds ratio, 1.62; p = 0.35) and if extracorporeal membranous oxygenation cannulation occurred in the emergency department versus other hospital locations (odds ratio, 2.52; p = 0.16). About 53 of 60 patients (88%) were neurologically intact at discharge or follow-up. Multivariate analysis demonstrated three-fold increase in the risk of death for patients greater than 65 years old (adjusted odds ratio, 3.08; p = 0.03) and six-fold increase if cannulation occurred during cardiopulmonary resuscitation (adjusted odds ratio, 5.67; p = 0.03). Conclusions Venoarterial extracorporeal membranous oxygenation has an emerging role in the management of massive PE-related cardiac arrest with 61% survival. Systemic thrombolysis preceding venoarterial extracorporeal membranous oxygenation did not confer a statistically significant increase in risk of death, yet age greater than 65 and cannulation during cardiopulmonary resuscitation were associated with a three- and six-fold risks of death, respectively.

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Background: The Bashir Endovascular Catheter (BEC) is a novel pharmaco-mechanical device designed to enhance thrombolysis by increasing the exposure of thrombus to endogenous and exogenous thrombolytics. The aim of this prospective, multicenter, single-arm study was to evaluate the feasibility and initial safety of the BEC in patients with acute intermediate-risk pulmonary embolism (PE). Methods: Patients with symptomatic PE and right ventricular to left ventricular diameter ratio ≥0.9 as documented by computer tomography angiography were eligible for enrollment. The primary safety end points were device related death or adverse events, and major bleeding within 72 hours after BEC directed therapy. Results: Nine patients were enrolled across 4 US sites. The total dose of r-tPA (recombinant tissue-type plasminogen activator) was 14 mgs in bilateral PE and 12 mgs in unilateral PE over 8 hours delivered via the expanded BEC. At 30-day follow-up, there were no deaths or device-related adverse events. At 48 hours post-BEC therapy, the right ventricular to left ventricular diameter ratio decreased from 1.52±0.26 to 0.97±0.06 ( P =0.0009 [95% CI, 0.33–0.82]; 37.0% reduction). Thrombus burden as measured by the Modified Miller Index decreased from 25.4±5.3 to 16.0±4.0 ( P =0.0005; [95% CI, 5.5–13.4]; 37.1% reduction). Conclusions: In this early feasibility study of the BEC for intermediate-risk PE, there were no deaths or device-related adverse events and a significant reduction in right ventricular to left ventricular diameter ratio and thrombus burden. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03927508.

BACKGROUND Venous thromboembolism (VTE) post lung transplantation is common and has been associated with worse post transplant survival . We report a comprehensive single center review of VTE incidence in the first post transplant year, investigate modifiable risk factors and assess impact on short term outcomes. METHODS Retrospective review of all lung transplant recipients between August 2016 to 2018 at Temple University Hospital. Patients were followed for 1 year post transplant. All patients were screened for deep venous thrombosis (DVT) within the first 2 weeks with a venous duplex study. Pre transplant, intra operative, post operative variables, and peri-operative practice patterns were compared between VTE positive and VTE negative groups. Logistic regression modeling was used to identify risk factors for early VTE (VTE within 30 days after transplant). RESULTS A total of 235 patients were included in the study, 58 patients (24.7%) developed a VTE in the first post transplant year. Median time to diagnosis was 17 days. Of the patients with VTE, 76% had an isolated DVT, 13.5 % had an isolated pulmonary embolism (PE), and 10.3% had concomitant DVT and PE. In a multivariate logistic regression model, cardiopulmonary bypass (CPB) (OR 1.93 p = 0.015) and interruption of VTE prophylaxis (OR 4.42 p CONCLUSION VTE post lung transplant is common despite the use of prophylactic anticoagulation . CPB use and interruption of DVT prophylaxis are risk factors for early post transplant VTE. Measures to ensure consistent and uninterrupted prophylaxis may help decrease VTE incidence after lung transplantation.

Background: Determine the impact of tobacco smoking status on patients hospitalized with COVID-19 pneumonia in the need for ICU care, mechanical ventilation and mortality. Methods: We performed a retrospective cohort study, that involved chart review. All adults 18 years or older with a diagnosis of COVID-19 pneumonia hospitalized from March 15th, 2020 to May 06th, 2020 with a positive reverse transcription polymerase chain reaction (RT-PCR) nasopharyngeal swab for COVID-19. We used chi-squared test for categorical variables and student t-tests or Wilcoxon rank sum tests for continuous variables. We further used adjusted and unadjusted logistic regression to assess risk factors for mortality and intubation.Results: Among 577 patients hospitalized with COVID-19 pneumonia, 268 (46.4%) had a history of smoking including 187 former and 81 active smokers. The former smokers when compared with non-smokers were predominantly older with more comorbidities. Also, when compared with never smokers D Dimer levels were elevated in active (p=0.05) and former smokers (pConclusions: In our cohort of hospitalized patients with COVID-19 pneumonia, former smokers had higher need for non-invasive respiratory support on admission, ICU care, and mortality compared to non-smokers. Also, active smokers versus non-smokers needed more mechanical ventilation.

Background Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. Methods We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. Results The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). Conclusions Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.

Introduction Use of high flow nasal therapy (HFNT) to treat COVID-19 pneumonia has been greatly debated around the world due to concern for increased healthcare worker transmission and delays in invasive mechanical Ventilation (IMV). Herein we analyze the utility of the ROX index to predict the need and timing for IMV in a retrospective analysis of patients with COVID-19 with moderate to severe hypoxemic respiratory failure treated with HFNT. Methods This was a retrospective analysis of 129 consecutive patients with COVID-19 admitted to Temple University Hospital in Philadelphia, Pennsylvania, from March 10, 2020, to May 17, 2020 with moderate to severe hypoxemic respiratory failure treated with High Flow nasal therapy (HFNT). HFNT patients were divided into two groups: HFNT only and HFNT progressed to IMV. The primary outcome was the ability of the ROX index to predict the need of IMV. Secondary outcomes were mortality, rates of intubation, length of stay (LOS) and rates of nosocomial infections in our cohort treated with HFNT were also reported. Results 837 patients with COVID-19 were screened, 129 met inclusion criteria. The mean age was 60.8(+13.6) years, BMI 32.6(+8), 58(45 %) were female, 72(55.8%) were African American, 40 (31%) Hispanic. 48 (37.2%) were smokers. Of the 129, 89 were HFNT only group whereas 40 in the HFNT progressed to IMV group. Mean time to intubation was 2.5 days(+ 3.3). The 89 HFNT only patients had a significant improvement in ROX from initiation of HFNT at all recorded time points. In contrast, the ROX in HFNT progressed to IMV patients remained unchanged or decreased over time. ROX index of less than 5 at HFNT initiation was predictive of progression to IMV (OR = 2.137, p = 0,052). Any decrease in ROX index after HFNT initiation was predictive of intubation (OR= 14.67, p 0), peak D-dimer >4000 and admission GFR < 60 ml/min were very strongly predictive of need for IMV (ROC = 0.86, p=0.001). Mortality was 11.2% in HFNT only group versus 47.5% in the HFNT progressed to IMV group (p = 0.0001). Mortality and need for pulmonary vasodilators were higher in the HNFT progressed to IMV group. Conclusion ROX index is a valuable, noninvasive tool to evaluate patients with moderate to severe hypoxemic respiratory failure in COVID-19 treated with HFNT. ROX helps predicts need for IMV and thus limiting morbidity and mortality associated with IMV.

Inferior vena cava (IVC) filters have existed as a treatment option for VTE for decades. Advances in medical technology have provided physicians with several options for devices that can be placed on either a permanent or temporary basis; however, there are limited data from randomized, controlled trials on the appropriate use of IVC filters. This contemporary review summarizes the history of IVC filters and the types that are available in clinical practice. It reviews the literature on the use of IVC filters and discusses the indications that professional societies have endorsed for their use. In addition, it outlines the complications of IVC filter placement and future research directions.

Venous thromboembolism (VTE) is a major cause of morbidity and mortality worldwide. Incidence of VTE and associated mortality is affected by the presence of risk factors, associated comorbid conditions, increased sensitivity and specificity of diagnostic testing, and advancement of VTE treatment options. In this chapter, we will discuss epidemiology of VTE in general, and then further focus on epidemiology of VTE based on various factors like age, gender, ethnicity, mortality, and impact of acquired and genetic VTE-related risk factors.

Inferior vena cava (IVC) filters have existed as a treatment option for venous thromboembolism for decades. Advances in medical technology have provided clinicians with several options of devices that can be placed on either a permanent or temporary basis. However, there are limited data from randomized, controlled trials on the appropriate use of IVC filters. This chapter will review and summarize the history of IVC filters and the types that are available in clinical practice. It will review the literature on the utilization of IVC filters and discuss the indications that professional societies have endorsed for their use. In addition, it will outline the complications of IVC filter placement and future research directions for this therapy option.

[Background]: Improved prediction of the risk of major bleeding in patients with acute pulmonary embolism (PE) receiving systemic thrombolysis is crucial to guide the choice of therapy. [Methods]: The study included consecutive patients with acute PE who received systemic thrombolysis in the RIETE registry. We used multivariable logistic regression analysis to create a risk score to predict 30-day major bleeding episodes. We externally validated the risk score in patients from the COMMAND VTE registry. In addition, we compared the newly created risk score against the Kuijer and RIETE scores., [Results]: Multivariable logistic regression identified four predictors for major bleeding: recent major bleeding (3 points), age >75 years (1 point), active cancer (1 point) and syncope (1 point) (BACS). Among 1172 patients receiving thrombolytic therapy in RIETE, 446 (38%) were classified as having low risk (none of the variables present, 0 points) of major bleeding according to the BACS score, and the overall 30-day major bleeding rate of this group was 2.9% (95% CI 1.6–4.9%), compared with 44% (95% CI 14–79%) in the high-risk group (>3 points). In the validation cohort, 51% (149 out of 290) of patients were classified as having low risk, and the overall 30-day major bleeding rate of this group was 1.3%. In RIETE, the 30-day major bleeding event rates in the Kuijer and RIETE low-risk strata were 5.3% and 4.4%, respectively., [Conclusions]: The BACS score is an easily applicable aid for prediction of the risk of major bleeding in the population of PE patients who receive systemic thrombolysis.

Pulmonary embolism (PE) presents a spectrum of hemodynamic consequences, ranging from being asymptomatic to a life-threatening medical emergency. Management of submassive and massive PE often involves clinicians from multiple specialties, which can potentially delay the development of a unified treatment plan. In addition, patients with submassive PE can deteriorate after their presentation and require escalation of care. Underlying comorbidities such as chronic obstructive pulmonary disease, cancer, congestive heart failure, and interstitial lung disease can impact the patient's hemodynamic ability to tolerate submassive PE. In this review, we address the definitions, risk stratification (clinical, laboratory, and imaging), management approaches, and long-term outcomes of submassive PE. We also discuss the role of the PE response team in management of patients with PE.

Invasive aspergillosis generally occurs during the first 1–6 months after heart transplantation. It has been rarely seen in the first 2 weeks postcardiac transplant. We herein describe a unique case of invasive pulmonary aspergillosis (IPA) diagnosed on day 9 postorthotopic heart transplantation. The known risk factors for IPA in cardiac transplant recipients were not identified in our case. The organ recipients from the same donor did not report Aspergillus infection. Hospital environmental samplings failed to demonstrate Aspergillus spores in the patient's room and his adjacent rooms. A diagnosis of early-onset de novo IPA was made. The patient initially received combined antifungal therapy (voriconazole plus micafungin), followed by voriconazole maintenance monotherapy with favorable clinical outcome.