Amaç: Masif pulmoner tromboemboli (PTE) tanısı alan hastaların semptomlarını, klinik ve radyolojik özelliklerini, uygulanan tedavi yöntemlerini, tedaviye yanıtlarını ve mortalite oranlarını değerlendirmek.Materyal ve metod: Fakültemiz Göğüs Hastalıkları Bölümü'nce 01 Ocak 2000 ile 01 Haziran 2010 tarihleri arasında masif PTE tanısı ile takip edilen 136 hasta retrospektif olarak incelendi.Hastaların genel özellikleri, PTE'ye predispozan faktörleri, semptomları, tanı ve tedaviye başlama zamanları, fizik muayene bulguları; akciğer grafisi, spiral bilgisayarlı tomografi (BT), ekokardiyografi (EKO), ventilasyon-perfüzyon (V/Q) sintigrafisi, alt ekstremite venöz dopler ultrasonografi (USG), elektrokardiyografi (ekg), laboratuar bulguları, hastanede yatış süreleri dosya ve bilgisayar otomasyon sisteminden kaydedildi.Ayrıca hastalar klinik skorlama sistemine göre değerlendirilerek kaydedildi. Uygulanan tedavi yöntemleri, tedaviye alınan cevap oranları, tedaviye bağlı komplikasyonlar ile mortalite oranları kaydedildi.Bulgular: Olguların 89'u (%65.4) kadın, 47'si (%34.6) erkek idi. K/E oranı 1.89, yaş ortalaması 63.54 idi. Predispozan faktörlere bakıldığında en çok 71 (%52.2) hasta ile ileri yaş izlendi. İkinci sırada 43 (%32.1) hasta ile immobilite izledi. Toplam 37 (%27.8) hastada ameliyat sonrası PTE geliştiği görüldü. Toplam 63 hastanın 35 (%55.5)'inde PTE açısından bakılan genetik faktör pozitifliği saptandı. En sık rastlanan bulgu 13 (%20.6) hasta ile metilen tetrahidrofolat redüktaz (MTHFR) heterozigot pozitifliği oldu. Hastaların 130 (%96.3)'unda nefes darlığı, 87 (%64.9)'sinde göğüs ağrısı, 54 (%40)'ünde bayılma olduğu görüldü. Fizik muayene bulgularından en sık 85 (%71.4) hasta ile taşikardi saptandı, daha sonra sırası ile 73 (%61.3) hipotansiyon, 58 (%48.7) bacaklarda çap farkı ve 58 (%48.7) hastada siyanoz bulundu. Ekokardiyografi yapılan 116 hastanın tamamında pulmoner arter basıncı (PAB) 30mm-Hg'nın üzerinde idi. 71 (%62.3) hastada interventriküler septal şift, 26 (%22.6) hastada septal paradoks hareket görüldü. 9 (%7.9) hastada aynı zamanda kardiyak trombüs olduğu tespit edildi. Trombolitik tedaviden 1 hafta sonra 86 hastada kontrol EKO yapıldı. 28 (%32.5) 'inde PAB 30mm-Hg'nın altına düşerek tamamen normale geldi. 71 (%82.5) hastanın ise PAB 45mm-Hg ve altında idi. Tanı anındaki ortalama PAB 67mm-Hg idi. Toplam 134 hastada Toraks CT Angiografi çekildi. Bunlardan 101 (%75.4) hastada trombüsün bilateral ana pulmoner arterde olduğu gözlendi. Hastaların 23 (%17.2)'ünde sağ ana pulmoner arterde, 4 (%3)'ünde sol ana pulmoner arterde trombüs izlendi. Derin ven trombozu (DVT) 52 (%39.1) hastada, interventriküler semtumda şift 86 (%64.7) hastada tespit edildi. V/Q Sintigrafisi yapılan 100 hastanın 88' inde yüksek olasılıklı, 10'unda orta olasılıklı, 2'sinde düşük olasılıklı pulmoner tromboemboli tespit edildi. Toplam 112 hastada alt ekstremite venöz dopler USG bakıldı. Bunlardan 76 (%67.8)'sında alt ekstremite venlerinde trombüs görüldü. Toplam 134 hastaya trombolitik tedavi uygulandı. Bunlardan 56 (%41.5)'sına doku plazminojen aktivatörü (TPA), 78 (%57.8)'ine streptokinaz (SKZ) uygulandı. Trombolitik tedavi sonrası majör kanama 2 (%1.5) hastada görüldü. Bunlardan biri intrakranyal kanama, diğeri ise masif hemoptizi idi. Minör hemoraji 19 (%14.2) hastada görülürken, hematom 14 (%10.4) hastada görüldü. Toplam 106 hastada 1. haftada tedavi sonrası Spiral Toraks BT Angiografi ile yanıt değerlendirilmesi yapıldı. Bunlardan 11 (%10.4) hastada yanıt görülmezken, 74 (%69.8) hastada tam veya tama yakın yanıt izlendi. 3. ayda yanıt değerlendirmesi yapılan 26 hastadan 20 (%76.9)'sinde tam, 5 (%19.2)'inde büyük oranda yanıt izlendi. V/P Sintigrafisi ile 85 hastada 1. haftada yapılan yanıt değerlendirmesinde 47 (%55.3)'sinde tam ve tama yakın yanıt görüldü. 7 (%8.2) hastada yanıt izlenmedi. Bir yılın sonunda hastaların önemli bir kısmında takipsizlik nedeni ile yanıt değerlendirilmesi tam olarak tespit edilemedi. Fakat genel olarak bakıldığında; 69 (%50.7) hastada tam yanıt, 13 (%9.6) kısmi yanıt, 7 (%5.1) hastada nüks, 9 hastada (%6.6) kronikleşme, 7 (%5.1) hastada bilinmiyor iken, 31 (%22.8) hastada ölüm görüldü. Antikoagülan tedavi verilememesi nedeni ile 2 (%1.5) hastaya geçici, 8 (%6) hastaya ise kalıcı vena kava inferior (VCİ) filtresi uygulandı. Trombolitik tedavi olarak SKZ ve TPA alan hastalar mortalite açısından değerlendirildiğinde; SKZ alanlarda TPA alanlara göre mortalitenin 2.8 kat daha fazla olduğu tespit edildi (p<0.05). Trombolitik tedavi sonrası yanıt olan ve olmayan hastalar ile bir hafta sonra bakılan EKO'sunda PAB normale gelen ve gelmeyen hastalar yaş, cinsiyet, BT'de bilateral trombüs, alt ekstremite doplerde trombüs, hipotansiyon, genetik faktör pozitifliği, malignite olup olmamasına göre; ayrıca D-Dimer, PAO2 değerleri, tanıdan tedaviye kadar geçen süre açısından karşılaştırıldığında, istatistiksel olarak anlamlı bulunmadı (p>0.05). İleri yaş ve PAO2 değeri düşük hastalarda yanıtın daha az olduğu görüldü, fakat istatistiksel olarak anlamlı değildi (p=0.06).Sonuç: Masif PTE mortalite ve morbiditesi yüksek bir hastalıktır. Masif PTE düşünülen hastalara uygun tanı algoritmaları eşliğinde derhal tanı konulmalıdır. Spiral Toraks BT en önemli tanısal araçtır. Tedavi edilmeyen hastalarda mortalite hemen hemen kaçınılmazken, erken ve uygun tedavi ile mortalite belirgin oranda azaltılabilir. Bu anlamda trombolitik tedavi etkin ve güvenilir bir tedavi seçeneğidir. Belirgin risk faktörü olmayan hastalar genetik risk faktörü ve malignite açısından araştırılmalıdır.Anahtar Kelimeler:Masif pulmoner tromboemboli, trombolitik tedavi.

Objective: To evaluate symptoms, clinical and radiological features, applied treatment methods, response to treatment and mortality rates of patients who were diagnosed as massive pulmonary thromboembolism (PTE).Material and method: 136 patients who were followed by massive PTE diagnosis by our faculty Chest Diseases Department between 1 January 2000 and 1 June 2010 were evaluated as retrospectively.Patients? general features, predisposing factors to PTE, symptoms, time of diagnosis and treatment onset, physical examination findings, chest x-ray, spiral computed tomography (CT), echocardiography (ECO), ventilation/perfusion (V/Q) scintigraphy, lower extremity venous doppler ultrasonography (USG), electrocardiography (ECG), laboratory findings, hospitalization durations were recorded from files and computer automation system.Also, patients were recorded by evaluating according to clinical scoring system. Applied treatment methods, response rates to treatment, complications related to treatment and mortality rates were recorded.Results: 89 (%65.4) of cases were female and 47 (%34.6) were male. F/M rate was 1.89, the avarage of age was 63.54. When the predisposing factors were examined, elderliness was the most common seen factor by a count of 71 (%52.2) patients. Secondly, immobility was seen by a count of 43 (%32.1) patients. It was seen that PTE developed in totally 37 (%27.8) patients after operation. In 35 (%55.5) of 63 patients, genetic factor positivity was determined in terms of PTE. The most common seen finding was methylene tetrahydrofolate reductase (MTHFR) heterozygote positivity by a count of 13 (%20.6) patients. It was seen that there was shortness of breath in 130 (%96.3) patients, chest pain in 87 (%64.9) patients and syncope in 54 (%40) patients. From physical examination findings the most common seen was tachycardia by a count of 85 (%71.4) patients., then hypotension in 73 (%61.3) patients, caliber difference in legs in 58 (%48.7) patients and cyanosis in 58 (%48.7) patients respectively. The pulmonary artery pressure (PAP) was above 30 mmHg in all of the 116 patients that were performed echocardiography. Interventricular ceptal shift was seen in 71 (%62.3) patients and septal paradox movement was seen in 26 (%22.6) patients. In 9 (%7.9) patients, also cardiac thrombus was determined. The control ECO was performed in 86 patients one week after thrombolytic therapy. In 28 (%32.5) of them, PAP regressed to completely normal value by reducing under 30mm-Hg. In 71 (%82.5) patients, PAP was 45mm-Hg and below. The mean PAP value at the diagnosis time was 67mm-Hg. Chest CT angiography was performed in totally 134 patients. In 101 (%75.4) of them, it was seen that the thrombus was in bilateral main pulmonary artery. In 23 (%17.2) of patients the thrombus was observed in right main pulmonary artery and in 4 (%3) patients in left main pulmonary artery. Deep vein thrombosis (DVT) was determined in 52 (%39.1) patients, shift in interventricular ceptum was determined in 86 (%64.7) patients. Among 100 patients who were performed V/Q scintigraphy, high probably PTE in 88 patients, moderate probably PTE in 10 patients and low probably PTE in 2 patients was determined. In totally 112 patients, lower extremity venous doppler USG was applied. Among these patients thrombus in lower extremity veins was seen in 76 (%67.8) patients. Thrombolytic therapy was applied to totally 134 patients. To 56 (%41.5) of these patients tissue plasminogen activator (TPA) and to 78 (%57.8) of them streptokinase (SKS) treatment was applied. Major bleeding after thrombolytic therapy was seen in 2 (%1.5) patients. One of them was intracranial bleeding and the other was massive hemoptysis. While minor hemorrhage was seen in 9 (%14.2) patients, hematom was seen in 14 (%10.4) patients. Response evaluation after treatment in first week was performed by Spiral Chest CT Angiography in totally 106 patients. Among these patients, while no response was seen in 11 (%10.4) patients, complete or neerly complete response was seen in 74 (%69.8) patients. Among 26 patients who were performed response evaluation in 3th mounth, complete response in 20 (%76.9) patients and substantially response in 5 (%19.2) patients was observed. In response evaluation in 85 patients at first week by V/Q Scintigraphy, complete or neerly complete response wass seen in 47 (%55.3) patients. No response was observed in 7 (%8.2) patients. At the end of one year, the response evaluation couldn?t be completely determined because of lack of follow. But when looked generally, complete response was seen in 69 (%50.7) patients, local response in 13 (%9.6) patients, relapse in 7 (%5.1) patients, becoming chronic in 9 (%6.6) patients, unknown in 7 (%5.1) patients and death was in 31 (%22.8) patients. Because anticoagulant therapy couldn?t be applied, transient inferior vena cava filter was performed to 2 (%1.5) patients and permanent inferior vena cava filter was performed to 8 (%6) patients. When the patients who received SKS and TPA as thrombolytic therapy were evaluated in terms of mortality, it was determined that the mortality was 2.38 times more in patients that received SKS compared to paitients received TPA. (p<0.05). The patients with and without response to thrombolytic therapy and the patients that PAP measure returned to normal after a week follow up were compared in terms of age, gender, bilateral thrombosis in CT, thrombosis in lower extremity doppler ultrasound, hypotension, positivity of genetic factors, presence of malignancy otherwise D- Dimer, PAO2 levels, time from diagnosis to treatment, there was no significiant outcome (p>0.05). Less response was seen in patients with advanced age and low PAO2 level, but it was not statistically significant (p=0.06).Conclusion: Massive PTE is a disease that has a high mortality and morbidity. The patients who were suspected as massive PTE should be diagnosed immediately in company with appropriate diagnosis algorithms. Spiral chest BT is the most important diagnostic tool. While the mortality is inevitable in untreated patients, mortality could be decrased dramatically by early and appropiate treatment. In this sense, thrombolytic therapy is an effective and safety treatment preference. The patients who has no clear risk factor should be investigated in terms of genetic risk factor and malignancy.Keywords: Massive pulmonary thromboembolism, , thrombolytic therapy.