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Schmitz A, Schacht M, Butty S. Repeat angiography in patients undergoing conventional catheter-directed thrombolysis for submassive pulmonary embolism: a large single-center experience. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:664-670. [PMID: 34559051 DOI: 10.5152/dir.2021.20573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Few studies have examined conventional catheter directed thrombolysis (CDT) for the treatment of submassive pulmonary embolism (PE). Moreover, angiographic resolution of thrombus burden following CDT has infrequently been characterized. This study describes a single-center experience treating submassive PE with CDT while utilizing repeat angiography to determine treatment efficacy. METHODS A retrospective analysis of 140 consecutive patients who underwent CDT for submassive PE from December 2012 to June 2019 was performed. Angiographic resolution of thrombus burden after CDT was reported as high (>75%), moderate (51-75%), low (26-50%), or insignificant (≤25%). All angiograms were reviewed by two interventional radiologists. Secondary endpoints included reduction in pulmonary artery pressure (PAP) and clinical outcomes. Bleeding events were classified according to the Society of Interventional Radiology (SIR) adverse event criteria. RESULTS CDT was performed in 140 patients with a mean rtPA dose of 25.3 mg and a mean treatment time of 26.0 hours. Angiographic resolution of thrombus burden was high in 70.0%, moderate in 19.3%, low in 5.7%, and insignificant in 3.6%; in 2 patients (1.4%) repeat angiography was not performed. Systolic PAP was reduced (47 vs. 35 mmHg, p < 0.001), mean PAP was reduced (25 vs 21 mmHg, p < 0.001), and 129 patients (92.1%) improved clinically. Patients with high or moderate resolution of thrombus burden had a clinical improvement rate of 95.2%, while patients with low or insignificant thrombus burden resolution had a clinical improvement rate of 76.9% (p=0.011). Ten patients (7.1%) had hemodynamic or respiratory decompensation requiring mechanical ventilation, systemic thrombolysis, cardiopulmonary resuscitation, or surgical intervention. Seven patients (5.0%) experienced moderate bleeding events and one patient (0.7%) with metastatic disease developed severe gastrointestinal bleeding that resulted in death. Thirty-day mortality was 1.4%. CONCLUSION In patients with submassive PE undergoing CDT, angiographic resolution of thrombus burden is a safe and directly observable metric that can be used to determine procedural success. In this study, CDT with repeat angiography was associated with a 5.7% bleeding event rate and thirty-day mortality of 1.4%.
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Affiliation(s)
- Adam Schmitz
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Michael Schacht
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Sabah Butty
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
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Jaureguízar A, Jiménez D, Bikdeli B, Ruiz-Artacho P, Muriel A, Tapson V, López-Reyes R, Valero B, Kenet G, Monreal M. Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism. Chest 2021; 161:524-534. [PMID: 34478718 DOI: 10.1016/j.chest.2021.08.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known. RESEARCH QUESTION Does an association exist between baseline HR and PE outcome across the continuum of HR values? STUDY DESIGN AND METHODS The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes. RESULTS A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; OR, 1.7 for HR of 110-119 beats/min; OR, 1.9 for HR of 120-139 beats/min; and OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%. INTERPRETATION In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.
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Affiliation(s)
- Ana Jaureguízar
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Pedro Ruiz-Artacho
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain; Interdisciplinar Teragnosis and Radiosomics Research Group, Universidad de Navarra, Madrid, Spain
| | - Alfonso Muriel
- Department of Biostatistics, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | | | - Raquel López-Reyes
- Department of Pneumology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Gili Kenet
- Department of Pediatric Hemato-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona; Universidad Católica de Murcia, Murcia, Spain
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Ching CK, Leong BSH, Nair P, Chan KC, Seow E, Lee F, Heng K, Sewa DW, Lim TW, Chong DTT, Yeo KK, Fong WK, Anantharaman V, Lim SH. Singapore Advanced Cardiac Life Support Guidelines 2021. Singapore Med J 2021; 62:390-403. [PMID: 35001112 PMCID: PMC8804484 DOI: 10.11622/smedj.2021109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.
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Affiliation(s)
- Chi Keong Ching
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Praseetha Nair
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Kim Chai Chan
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Francis Lee
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Kenneth Heng
- Emergency Medicine Department, Tan Tock Seng Hospital, Singapore
| | - Duu Wen Sewa
- Department of Respiratory Medicine, Singapore General Hospital, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Hospital, Singapore
| | | | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Wee Kim Fong
- Department of Anaesthesia, Tan Tock Seng Hospital, Singapore
| | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Rali P, Sacher D, Rivera-Lebron B, Rosovsky R, Elwing JM, Berkowitz J, Mina B, Dalal B, Davis GA, Dudzinski DM, Duval A, Ichinose E, Kabrhel C, Kapoor A, Lio KU, Lookstein R, McDaniel M, Melamed R, Naydenov S, Sokolow S, Rosenfield K, Tapson V, Bossone E, Keeling B, Channick R, Ross CB. Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities. Chest 2021; 160:1844-1852. [PMID: 34273391 DOI: 10.1016/j.chest.2021.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Parth Rali
- Temple University Hospital, Philadelphia, PA.
| | | | | | - Rachel Rosovsky
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jean M Elwing
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Bhavinkumar Dalal
- Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | | | | | | | | | | | | | - Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | | | | | | | | | | | | | | | | | | | - Charles B Ross
- Piedmont Heart Institute, Piedmont Atlanta Hospital, Atlanta, GA
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Sessa F, Esposito M, Messina G, Di Mizio G, Di Nunno N, Salerno M. Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance. Healthcare (Basel) 2021; 9:870. [PMID: 34356248 PMCID: PMC8307931 DOI: 10.3390/healthcare9070870] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/27/2022] Open
Abstract
The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.
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Affiliation(s)
- Francesco Sessa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Massimiliano Esposito
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
| | - Giovanni Messina
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Giulio Di Mizio
- Forensic Medicine, Department of Law, Economy and Sociology, Campus “S. Venuta”, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Nunzio Di Nunno
- Department of History, Society and Studies on Humanity, University of Salento, 73100 Lecce, Italy;
| | - Monica Salerno
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
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Acar E, Kilicgedik A, Izci S, Inanir M, Yilmaz MF, Gokce M, Izgi IA, Kirma C. Time interval between E and E' waves can predict complicated clinical course in patients with acute pulmonary embolism. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:580-585. [PMID: 33660282 DOI: 10.1002/jcu.22995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/02/2021] [Accepted: 02/12/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE Acute pulmonary embolism is a life-threatening cardiothoracic emergency leading to right ventricle systolic and diastolic dysfunction. In the present study, we investigated the right ventricle diastolic function and its predictive value in patients with acute pulmonary embolism. MATERIAL AND METHODS Were prospectively recruited in this study 621 patients diagnosed with acute pulmonary embolism between December 2015 and June 2019. Among them, 173 were excluded, leaving 448 patients for follow-up. Transthoracic echocardiography was performed for the evaluation of the right ventricle systolic and diastolic indices. At 30-day follow-up, the patients were allocated either into the benign or in the complicated clinical course group. RESULTS The group with complicated clinical course had higher value of pulmonary artery systolic pressure (PASP), right/left ventricle diameter ratio, E-wave velocity, E/A ratio, A' wave velocity, E/E' ratio, and time interval between E and E' waves (P < .05), but lower values of tricuspid annular plane systolic excursion, A-wave velocity, isovolumetric relaxation time, deceleration time, E', and E'/A' (P < .05). Complicated clinical course was associated with shorter isovolumetric relaxation time (r = .564, P < .001), E/E' (r = .495, P < .001), and TE-E' (r = .596, P < .001). Receiver operator characteristic curve analysis showed that TE-E' had the largest area under curve (TE-E' 0.82, IVRT 0.77, E/E' 0.72). A cut-off value of TE-E' = 70 milliseconds had an 81.1% sensitivity and 71.4% specificity for the prediction of the complicated clinical course. CONCLUSION The assessment of the right ventricle diastolic function could predict the complicated clinical course in patients with acute pulmonary embolism.
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Affiliation(s)
- Emrah Acar
- Department of Cardiology, Gumushane State Hospital, Gumushane, Turkey
| | - Alev Kilicgedik
- Department of Cardiology, Kartal Koşuyolu Heart and Vascular Disease Research and Training Hospital, Istanbul, Turkey
| | - Servet Izci
- Department of Cardiology, Kartal Koşuyolu Heart and Vascular Disease Research and Training Hospital, Istanbul, Turkey
| | - Mehmet Inanir
- Faculty of Medicine, Department of Cardiology, Abant Izzet Baysal University, Bolu, Turkey
| | - Mehmet Fatih Yilmaz
- Department of Cardiology, Siyami Ersek Heart and Vascular Disease Research and Training Hospital, Istanbul, Turkey
| | - Mustafa Gokce
- Faculty of Medicine, Department of Cardiology, Karadeniz Technical University, Trabzon, Turkey
| | - Ibrahim Akin Izgi
- Department of Cardiology, Kartal Koşuyolu Heart and Vascular Disease Research and Training Hospital, Istanbul, Turkey
| | - Cevat Kirma
- Department of Cardiology, Kartal Koşuyolu Heart and Vascular Disease Research and Training Hospital, Istanbul, Turkey
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Abdelghani E, Cua CL, Giver J, Rodriguez V. Thrombosis Prevention and Anticoagulation Management in the Pediatric Patient with Congenital Heart Disease. Cardiol Ther 2021; 10:325-348. [PMID: 34184214 PMCID: PMC8555036 DOI: 10.1007/s40119-021-00228-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombosis is one of the most frequent complications affecting children with congenital heart disease (CHD). Palliative and reparative cardiac surgeries are some of the main players contributing to the thrombosis risk in this patient population. Additional risk factors related to the CHD itself (e.g., cardiac dysfunction, arrhythmias, and polycythemia in cyanotic cardiac disorders) can contribute to thrombogenicity alone or combined with other factors. Thrombotic complications have been recognized as a significant cause of morbidity and mortality in this patient population. Here, we provide an overview of the pathophysiology and risk factors for thrombosis as well as the indications for and use of different anticoagulation, antiplatelet, and thrombolytic agents. In addition, we describe some of most common thrombotic complications and their management in the pediatric CHD population.
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Affiliation(s)
- Eman Abdelghani
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
| | - Jean Giver
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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Li K, Cui M, Zhang K, Liang K, Liu H, Zhai S. Treatment of acute pulmonary embolism using rheolytic thrombectomy. EUROINTERVENTION 2021; 17:e158-e166. [PMID: 32863245 PMCID: PMC9725013 DOI: 10.4244/eij-d-20-00259] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The AngioJet rheolytic thrombectomy (ART) system can quickly fragment and aspirate thrombi according to Bernoulli's principle. AIMS This retrospective study aimed to evaluate the therapeutic effects of the ART system in treating severe acute pulmonary embolism (APE), including high-risk pulmonary embolism (HR-PE) and intermediate-high-risk pulmonary embolism (IHR-PE). METHODS Forty-four APE patients (21 HR-PE and 23 IHR-PE) were enrolled and underwent pulmonary ART using the 6 Fr Solent Omni AngioJet device. Nineteen patients were diagnosed with APE and lower extremity deep venous thrombosis (LEDVT), and underwent thrombectomy of APE and LEDVT simultaneously using ART. All patients also received local thrombolysis with urokinase. RESULTS The results showed that the mean length of stay in intensive care units was 2.4±1.9 days. Significant improvements in clinical, haemodynamic and angiographic parameters were observed in both groups; the improvements in shock index, PaO2, and angiographic parameters were more obvious in the IHR-PE group. Six of the 44 patients died in hospital. During the follow-up, 35 of 38 patients were functioning well and no recurrence of APE was observed. CONCLUSIONS Pulmonary ART plus local thrombolysis of the pulmonary artery for HR-PE or IHR-PE is feasible and appears to be safe. Further studies are warranted to investigate comparative efficacy compared to existing treatments.
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Affiliation(s)
- Kun Li
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Mingzhe Cui
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kewei Zhang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kai Liang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Heng Liu
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Shuiting Zhai
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, 7 Weiwu Road, Zhengzhou, Henan, 450003, China
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Rubini G, Ferrari C, Mammucci P, Pisani AR, Mincarone P, Leo CG. Healthcare and Economic Impact of Lung Perfusion Scintigraphy in Patients Affected by Acute Pulmonary Embolism. Healthcare (Basel) 2021; 9:healthcare9060716. [PMID: 34200953 PMCID: PMC8230672 DOI: 10.3390/healthcare9060716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
Acute pulmonary embolism (APE) is a cardiovascular emergency, representing the main cause of mortality, morbidity, and hospitalisation in Europe. We aim to evaluate the economic and healthcare impact of lung perfusion scintigraphy (LPS) used in patients with suspected APE, in the event of non-conclusive or contraindicated computed tomography pulmonary angiography (CTPA). We considered two alternative healthcare processes for APE diagnosis, with and without LPS. We performed a cost analysis with the aim of evaluating the average direct healthcare costs for diagnosis, risk assessment, and treatment of APE. We used data from a monocentric trial. Our economic model showed that the strategy with LPS was preferable in terms of costs. The average per-patient costs for the diagnosis and treatment of the acute phase of PE in low-risk patients with a non-conclusive or not-executable CTPA, with and without LPS, are EUR 2145.25 and EUR 4912.45, respectively. LPS is a simple, quick, and economic examination, useful in this setting of patients not only for an early diagnosis but also to exclude APE, demonstrating an advantage in terms of healthcare resources. To the best of our knowledge, this study is the first to analyse the economic and healthcare impact of the use of LPS in the diagnostic pathway of suspected APE.
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Affiliation(s)
- Giuseppe Rubini
- Section of Nuclear Medicine, Interdisciplinary Department of Medicine, University Aldo Moro of Bari, 70124 Bari, Italy; (G.R.); (P.M.); (A.R.P.)
| | - Cristina Ferrari
- Section of Nuclear Medicine, Interdisciplinary Department of Medicine, University Aldo Moro of Bari, 70124 Bari, Italy; (G.R.); (P.M.); (A.R.P.)
- Correspondence: ; Tel.: +39-08-0559-5039
| | - Paolo Mammucci
- Section of Nuclear Medicine, Interdisciplinary Department of Medicine, University Aldo Moro of Bari, 70124 Bari, Italy; (G.R.); (P.M.); (A.R.P.)
| | - Antonio Rosario Pisani
- Section of Nuclear Medicine, Interdisciplinary Department of Medicine, University Aldo Moro of Bari, 70124 Bari, Italy; (G.R.); (P.M.); (A.R.P.)
| | - Pierpaolo Mincarone
- Research Unit of Brindisi, Institute for Research on Population and Social Policies, National Research Council, 72100 Brindisi, Italy;
| | - Carlo Giacomo Leo
- Institute of Clinical Physiology, National Research Council, Branch of Lecce, c/o Campus Ecotekne via Provinciale Lecce-Monteroni, 73100 Lecce, Italy;
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Current Management of Acute Pulmonary Embolism. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00293-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Patel JJ, Bergl PA. Confirm, Don't Conform Toward Thrombolysis in Acute Pulmonary Embolism in Out-of-Hospital Cardiac Arrest. Chest 2021; 157:1396-1397. [PMID: 32386645 DOI: 10.1016/j.chest.2019.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Paul A Bergl
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
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Cozzi D, Moroni C, Cavigli E, Bindi A, Caviglioli C, Nazerian P, Vanni S, Miele V, Bartolucci M. Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism. Radiol Med 2021; 126:1030-1036. [PMID: 33961187 DOI: 10.1007/s11547-021-01364-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department. METHODS This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis. RESULTS The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively. CONCLUSION CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.
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Affiliation(s)
- Diletta Cozzi
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy.
| | - Chiara Moroni
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Edoardo Cavigli
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Alessandra Bindi
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Cosimo Caviglioli
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Simone Vanni
- Department of Emergency Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
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Kim J, Lee Y, Park HO, Shin IW. Management of perioperative acute massive pulmonary embolism: A case series. Clin Case Rep 2021; 9:e04078. [PMID: 34084497 PMCID: PMC8142415 DOI: 10.1002/ccr3.4078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 11/07/2022] Open
Abstract
The management of acute massive pulmonary embolism during the perioperative period is challenging. Accurate diagnosis using echocardiography and application of rapid extracorporeal membrane oxygenation can improve patients' outcomes.
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Affiliation(s)
- Ji‐Yoon Kim
- Department of Anesthesiology and Pain MedicineSchool of MedicineKyungpook National UniversityKyungpook National University Medical CenterDaeguSouth Korea
| | - Young‐Seok Lee
- Department of NeurosurgerySchool of MedicineKyungpook National UniversityKyungpook National University Medical CenterDaeguSouth Korea
| | - Hyun Oh Park
- Department of Thoracic and Cardiovascular SurgeryGyeongsang National University HospitalJinjuKorea
| | - Il Woo Shin
- Department of Anesthesiology and Pain MedicineGyeongsang National University College of MedicineJinjuKorea
- Institute of Health SciencesGyeongsang National UniversityJinjuKorea
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65
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Advanced therapies for pulmonary embolism. Curr Opin Pulm Med 2021; 26:397-405. [PMID: 32740381 DOI: 10.1097/mcp.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Treatment options for managing patients with acute pulmonary embolism are rapidly evolving. In this review, we discuss the supporting evidence and implementation strategies for these advanced therapeutic modalities. RECENT FINDINGS We review the recent data supporting systemic and catheter directed thrombolytic therapies, mechanical embolectomy, use of extracorporeal membrane oxygen support, and pulmonary embolism response teams in managing patients with acute pulmonary embolism. We discuss the major professional society recommendations regarding their implementation. SUMMARY A review of advanced therapies for pulmonary embolism.
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66
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Peng D, Hou ZL, Zhang HX, Zhang S, Zhang SM, Lin RY, Xing ZC, Yuan Y, Yang KY, Wang JX. Microarray Expression Profile and Analysis of Circular RNA Regulatory Network in Pulmonary Thromboembolism. Int J Gen Med 2021; 14:1239-1249. [PMID: 33859492 PMCID: PMC8043787 DOI: 10.2147/ijgm.s304199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/18/2021] [Indexed: 11/23/2022] Open
Abstract
Background Pulmonary thromboembolism (PTE) is a common disease which may be a serious condition and has high mortality. Recently, it has been shown that circRNAs play an important role in the development of various diseases, including thromboembolic disease. However, circRNAs expression profiling is not clear in PTE, this study aims to identify the circRNAs expressed in PTE and to elucidate their possible role in pathophysiology of PTE. Methods A total of 5 patients with CTPA-confirmed PTE and 5 healthy controls were recruited for the present study. The circRNAs expression profile was analyzed by microarray. Results In total, 256 differentially expressed circRNAs (up 142, down114) and 1162 mRNA (up 446, down 716) were summarized by analyzing the circRNAs microarray data. The top 3 up-regulated and 3 down-regulated circRNAs were validated by Real-Time Polymerase Chain Reaction (qRT-PCR). Two differentially expressed circRNAs (hsa_circ_0000891, hsa_circ_0043506) were selected for further analysis. Finally, we construct a circRNA-miRNA-mRNA ceRNA network with a bioinformatic prediction tool. Pathway analysis shows that the enriched mRNAs targets take part in Protein processing in endoplasmic reticulum, Systemic lupus erythematosus, Endocytosis, Spliceosome, HTLV-I infection and Ubiquitin mediated proteolysis. Conclusion Our findings indicated that aberrantly expressed circRNAs (hsa_circ_0000891, hsa_circ_0043506) may be involved in the development of PTE.
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Affiliation(s)
- Dan Peng
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zi-Liang Hou
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hong-Xia Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuai Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shu-Ming Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Rui-Yan Lin
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhen-Chuan Xing
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yuan Yuan
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Kai-Yuan Yang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jin-Xiang Wang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
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67
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Zhou C, Chan HP, Chughtai A, Patel S, Kuriakose J, Hadjiiski LM, Wei J, Kazerooni EA. Variabilities in Reference Standard by Radiologists and Performance Assessment in Detection of Pulmonary Embolism in CT Pulmonary Angiography. J Digit Imaging 2021; 32:1089-1096. [PMID: 31073815 DOI: 10.1007/s10278-019-00228-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Annotating lesion locations by radiologists' manual marking is a key step to provide reference standard for the training and testing of a computer-aided detection system by supervised machine learning. Inter-reader variability is not uncommon in readings even by expert radiologists. This study evaluated the variability of the radiologist-identified pulmonary emboli (PEs) to demonstrate the importance of improving the reliability of the reference standard by a multi-step process for performance evaluation. In an initial reading of 40 CTPA PE cases, two experienced thoracic radiologists independently marked the PE locations. For markings from the two radiologists that did not agree, each radiologist re-read the cases independently to assess the discordant markings. Finally, for markings that still disagreed after the second reading, the two radiologists read together to reach a consensus. The variability of radiologists was evaluated by analyzing the agreement between two radiologists. For the 40 cases, 475 and 514 PEs were identified by radiologists R1 and R2 in the initial independent readings, respectively. For a total of 545 marks by the two radiologists, 81.5% (444/545) of the marks agreed but 101 marks in 36 cases differed. After consensus, 65 (64.4%) and 36 (35.6%) of the 101 marks were determined to be true PEs and false positives (FPs), respectively. Of these, 48 and 17 were false negatives (FNs) and 14 and 22 were FPs by R1 and R2, respectively. Our study demonstrated that there is substantial variability in reference standards provided by radiologists, which impacts the performance assessment of a lesion detection system. Combination of multiple radiologists' readings and consensus is needed to improve the reliability of a reference standard.
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Affiliation(s)
- Chuan Zhou
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Heang-Ping Chan
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aamer Chughtai
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Smita Patel
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jean Kuriakose
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lubomir M Hadjiiski
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jun Wei
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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68
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Yang F, Wang D, Cui S, Zhu Y, Liu L, Ji M, Zou D, Zhao R, Liu Q. Decreased pulmonary artery distensibility as a marker for severity in acute pulmonary embolism patients undergoing ECG-gated CTPA. J Thromb Thrombolysis 2021; 51:748-756. [PMID: 33738769 DOI: 10.1007/s11239-021-02397-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
To investigate the characteristics of pulmonary artery distensibility (PAD) in patients with acute pulmonary embolism (APE) and to assess whether a relationship exists between PAD and the disease severity. Clinical and radiological data of 30 APE patients who underwent retrospective electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) with a definite diagnosis of APE were retrospectively reviewed in the present study, including 15 subjects in severe (SPE) group and 15 subjects in non-severe (NSPE) group. PAD and cardiac function parameters were compared between the two groups, their relationships were investigated, and receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the above parameters for the diagnosis of APE severity. The PAD decreased in the following order: NSPE group (6.065 ± 2.114) × 10-3 (%/mmHg), and SPE group (4.334 ± 1.777) × 10-3 (%/mmHg) (P < 0.05). All the cardiac function parameters except RA/LAdiameter showed statistically significant different values between the two groups (P < 0.05). As APE severity increased, the cardiac morphological measurements of RV/LVdiameter, RV/LVarea, RVEDV/LVEDV and RVESV/LVESV increased. There was a weak to moderate negative correlation between PAD and PAmax, PAmin, PA/AAmin, PA/AAmax, RV/LVdiameter, RV/LVarea (r = -0.393 to -0.625), that is, PAD was inversely correlated with cardiac function parameters. There was a moderate negative correlation between PAD and hemoptysis(r = -0.672). The area under the ROC curve (AUC) of PAD was 0.724, the critical value was 4.137 × 10-3 mm/Hg, and the sensitivity and specificity were 60.0% and 93.3%, respectively. PAmin showed the strongest discriminatory power to identify high-risk patients (AUC = 0.827), with the highest sensitivity of 100%, which was also achieved by RA/LAarea. The PAD obtained by retrospective ECG-gated CTPA could be an indicator to be used in the evaluation of the presence and severity of APE.
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Affiliation(s)
- Fei Yang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China.
| | - Dawei Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Shujun Cui
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Yuexiang Zhu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Lan Liu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Mengmeng Ji
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Dianjun Zou
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Ru Zhao
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Qingxiao Liu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
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Castillo E, Nair G, Turner-Lawrence D, Myziuk N, Emerson S, Al-Katib S, Westergaard S, Castillo R, Vinogradskiy Y, Quinn T, Guerrero T, Stevens C. Quantifying pulmonary perfusion from noncontrast computed tomography. Med Phys 2021; 48:1804-1814. [PMID: 33608933 PMCID: PMC8252085 DOI: 10.1002/mp.14792] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Computed tomography (CT)‐derived ventilation methods compute respiratory induced volume changes as a surrogate for pulmonary ventilation. Currently, there are no known methods to derive perfusion information from noncontrast CT. We introduce a novel CT‐Perfusion (CT‐P) method for computing the magnitude mass changes apparent on dynamic noncontrast CT as a surrogate for pulmonary perfusion. Methods CT‐Perfusion is based on a mass conservation model which describes the unknown mass change as a linear combination of spatially corresponding inhale and exhale HU estimated voxel densities. CT‐P requires a deformable image registration (DIR) between the inhale/exhale lung CT pair, a preprocessing lung volume segmentation, and an estimate for the Jacobian of the DIR transformation. Given this information, the CT‐P image, which provides the magnitude mass change for each voxel within the lung volume, is formulated as the solution to a constrained linear least squares problem defined by a series of subregional mean magnitude mass change measurements. Similar to previous robust CT‐ventilation methods, the amount of uncertainty in a subregional sample mean measurement is related to measurement resolution and can be characterized with respect to a tolerance parameter τ. Spatial Spearman correlation between single photon emission CT perfusion (SPECT‐P) and the proposed CT‐P method was assessed in two patient cohorts via a parameter sweep of τ. The first cohort was comprised of 15 patients diagnosed with pulmonary embolism (PE) who had SPECT‐P and 4DCT imaging acquired within 24 h of PE diagnosis. The second cohort was comprised of 15 nonsmall cell lung cancer patients who had SPECT‐P and 4DCT images acquired prior to radiotherapy. For each test case, CT‐P images were computed for 30 different uncertainty parameter values, uniformly sampled from the range [0.01, 0.125], and the Spearman correlation between the SPECT‐P and the resulting CT‐P images were computed. Results The median correlations between CT‐P and SPECT‐P taken over all 30 test cases ranged between 0.49 and 0.57 across the parameter sweep. For the optimal tolerance τ = 0.0385, the CT‐P and SPECT‐P correlations across all 30 test cases ranged between 0.02 and 0.82. A one‐sample sign test was applied separately to the PE and lung cancer cohorts. A low Spearmen correlation of 15% was set as the null median value and two‐sided alternative was tested. The PE patients showed a median correlation of 0.57 (IQR = 0.305). One‐sample sign test was statistically significant with 96.5 % confidence interval: 0.20–0.63, P < 0.00001. Lung cancer patients had a median correlation of 0.57(IQR = 0.230). Again, a one‐sample sign test for median was statistically significant with 96.5 percent confidence interval: 0.45–0.71, P < 0.00001. Conclusion CT‐Perfusion is the first mechanistic model designed to quantify magnitude blood mass changes on noncontrast dynamic CT as a surrogate for pulmonary perfusion. While the reported correlations with SPECT‐P are promising, further investigation is required to determine the optimal CT acquisition protocol and numerical method implementation for CT‐P imaging.
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Affiliation(s)
- Edward Castillo
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA.,Department of Computational and Applied Mathematics, Rice University, Houston, TX, USA
| | - Girish Nair
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | | | - Nicholas Myziuk
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Scott Emerson
- Department of Diagnostic Radiology, Beaumont Health, Royal Oak, MI, USA
| | - Sayf Al-Katib
- Department of Diagnostic Radiology, Beaumont Health, Royal Oak, MI, USA
| | - Sarah Westergaard
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Richard Castillo
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | | | - Thomas Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA
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70
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Murray JL, Zapata D, Keeling WB. High-Risk Pulmonary Embolism: Embolectomy and Extracorporeal Membrane Oxygenation. Semin Respir Crit Care Med 2021; 42:263-270. [PMID: 33592654 DOI: 10.1055/s-0041-1722868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Pulmonary embolism (PE) is a common medical condition associated with significant morbidity and mortality. It is the third most common cause of death in the United States. Historically, surgery for PE was associated with a high mortality rate, and this led to a significant decrease in the volume of operations being performed. However, significant improvements in patient selection and outcomes for surgical pulmonary embolectomy (SPE) at the end of the 20th century led to a renewed interest in the procedure. SPE was historically reserved for patients presenting with acute PE and hemodynamic collapse or cardiac arrest. Contemporary data has provided sufficient evidence to support earlier intervention for patients with acute PE who demonstrate clinical, laboratory, and echocardiographic signs of right ventricular dysfunction. Institutions with cardiac surgery capabilities are implementing SPE earlier for the management of both massive and submassive PEs with excellent short-term and long-term outcomes. Recently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been employed successfully to treat patients with massive PE. Excellent short-term outcomes have been reported for patients suffering from PE after treatment with VA-ECMO. Further research, specifically with randomized controlled trials, is needed to determine the appropriate timing and patient selection for the use of VA-ECMO in patients with PE. These data would lead to updated guidelines and algorithms incorporating VA-ECMO and SPE for patients with PE.
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Affiliation(s)
- John L Murray
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - David Zapata
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - William B Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Cardiothoracic Surgery Service, Grady Memorial Hospital, Atlanta, Georgia
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71
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Buchanan FR, Leede E, Brown LH, Teixeira PG, Aydelotte JD, Cardenas TC, Coopwood TB, Trust MD, Ali S, Brown CVR. Risk scoring models fail to predict pulmonary embolism in trauma patients. Am J Surg 2021; 222:855-860. [PMID: 33608103 DOI: 10.1016/j.amjsurg.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE). METHODS We performed a retrospective review (2014-2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared. RESULTS Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE. CONCLUSIONS In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.
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Affiliation(s)
- Frank R Buchanan
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Emily Leede
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Lawrence H Brown
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Jayson D Aydelotte
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Tatiana C Cardenas
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Thomas B Coopwood
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Marc D Trust
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
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Gök G, Karadağ M, Çinar T, Nurkalem Z, Duman D. In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism. J Cardiovasc Thorac Res 2021; 12:321-327. [PMID: 33510882 PMCID: PMC7828758 DOI: 10.34172/jcvtr.2020.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury.
Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records.
Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality.
Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.
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Affiliation(s)
- Gulay Gök
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Mehmet Karadağ
- Hatay Mustafa Kemal University Faculty of Medicine, Department of Biostatistics, Hatay, Turkey
| | - Tufan Çinar
- Health Sciences University, Sultan 2. Abdülhamid Han Training and Research Hospital, Department of Cardiology, İstanbul, Turkey
| | - Zekeriya Nurkalem
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Dursun Duman
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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Wang D, Yang F, Zhu X, Cui S, Dong S, Zhang Z, Zhang Y. CTPA pulmonary artery distensibility in assessment of severity of acute pulmonary embolism and right ventricular function. Medicine (Baltimore) 2021; 100:e24356. [PMID: 33546070 PMCID: PMC7837935 DOI: 10.1097/md.0000000000024356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/22/2020] [Indexed: 12/03/2022] Open
Abstract
To investigate the characteristics of pulmonary artery distensibility (PAD) in patients with acute pulmonary embolism (APE) and to assess the correlation of PAD with APE severity and right ventricular function. A total of 33 patients who underwent retrospective electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) with a definite diagnosis of APE were included in the study. According to APE severity, the patients were divided into severe (SPE) and non-severe (NSPE) groups. Data from a control group without APE matching the basic demographics of the APE patients were collected. Pulmonary artery distensibility (PAD) and right ventricular function parameters were compared among the 3 groups, their relationships were investigated, and receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the above parameters for the diagnosis of APE severity. The PAD values of the control, NSPE, and SPE groups were (7.877 ± 2.637) × 10-3 mm/Hg, (6.050 ± 2.011) × 10-3 mm/Hg, (4.321 ± 1.717) × 10-3 mm/Hg, respectively (P < .01). There were statistically significant differences in right ventricular function parameters among the 3 groups (P < .05). The correlation analysis between PAD and right ventricular function parameters showed a weak negative correlation (r = -0.281--0.392). The area under the ROC curve of PAD was 0.743, the critical value was 4.200, and the sensitivity and specificity were 62.5% and 94.1%, respectively. The PAD obtained by retrospective ECG-gated CTPA could accurately evaluate APE severity and right ventricular function. As the severity of APE increases, PAD decreases, which is helpful to identify patients at high risk of APE.
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Affiliation(s)
| | - Fei Yang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Xiaolong Zhu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Shujun Cui
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Shanglin Dong
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | | | - Yujiao Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
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Xing X, Liu J, Deng Y, Xu S, Wei L, Yang M, He X, Cao B, Huang X, Yue Q, Yang J, Teng Z. Impact of renal function on the prognosis of acute pulmonary embolism patients: a systematic review and meta-analysis. Expert Rev Respir Med 2020; 16:91-98. [PMID: 33297795 DOI: 10.1080/17476348.2021.1862653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES We conduct a study to explore the influence of impaired renal function on prognosis in Acute pulmonary embolism (APE) patients. METHODS A meta-analysis was performed using the EMBASE and PubMed databases for relevant publications reporting the impact of impaired renal function on the clinical outcomes in patients with APE. RESULTS Eventually, 17 articles were included in our analysis. The results suggested that renal insufficiency (RI) is a predictor of poor prognosis in APE patients(short-term mortality: pooled OR = 2.83, 95%CI: 2.20-3.63; long-term mortality: pooled OR = 2.30, 95%CI: 1.72-3.08; adverse outcomes: pooled OR = 3.02, 95%CI: 2.60-3.51). The short-term and long-term mortality rates of APE patients with RI were both higher than those in patients without RI. In addition, acute kidney injury(AKI) could serve as a predictive factor of poor prognosis (pooled OR = 2.75, 95%CI: 2.45-3.08), and it doubles the overall mortality rate in APE patients. However, chronic kidney disease (CKD) did not predict poor prognosis in APE patients (pooled OR = 1.94, 95%CI: 0.99-3.81), although it could slightly increase the overall mortality rate in APE patients. CONCLUSIONS RI and AKI could be included in the prognosis evaluation for APE, but the impact of CKD in APE patients has yet to be determined.
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Affiliation(s)
- Xiqian Xing
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Jie Liu
- Department of Respiratory Medicine, The Fourth Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yishu Deng
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Shuanglan Xu
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Li Wei
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Mei Yang
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Xiaohua He
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Bing Cao
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Xiaoxian Huang
- Department of Respiratory Medicine, The Affiliated Hospital of Yunnan University, the Second People's Hospital of Yunnan Province, Kunming, China
| | - Qiaoning Yue
- Department of Orthopedic Surgery, The People's Hospital of Yuxi City, the Sixth Affiliated Hospital of Kunming Medical University, Yuxi, China
| | - Jiao Yang
- First Department of Respiratory Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhaowei Teng
- Department of Orthopedic Surgery, The People's Hospital of Yuxi City, the Sixth Affiliated Hospital of Kunming Medical University, Yuxi, China
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Mirambeaux R, Le Mao R, Muriel A, Pintado B, Pérez A, Velasco D, Lobo JL, Barrios D, Morillo R, Bikdeli B, Jiménez D. Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2020; 26:1076029620967760. [PMID: 33315469 PMCID: PMC7739071 DOI: 10.1177/1076029620967760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Raphael Le Mao
- Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), 137662Université Européenne de Bretagne, Brest, France
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Beatriz Pintado
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Andrea Pérez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Diurbis Velasco
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - José Luis Lobo
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Respiratory Department, 37487Hospital Araba, Vitoria, Spain
| | - Deisy Barrios
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, NY, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA.,Cardiovascular Research Foundation, NY, USA
| | - David Jiménez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Medicine Department, Alcala de Henares University, IRYCIS, Madrid, Spain
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76
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Zuin M, Barco S, Zuliani G, Roncon L. Management of high-risk pulmonary embolism in an “unstable medical environment”: Not only a matter of hemodynamic. Thromb Res 2020; 195:193-194. [DOI: 10.1016/j.thromres.2020.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/23/2022]
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77
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
OBJECTIVES To compare the hemodynamic effects of increased versus decreased preload in a porcine model of acute intermediate-risk pulmonary embolism. DESIGN Randomized, controlled animal study. SETTING Tertiary medical center, animal research laboratory. SUBJECTS Female, Danish slaughter pigs (n = 22, ~ 60 kg). INTERVENTIONS Acute pulmonary embolism was induced by large emboli made from clotting of autologous blood. Sixteen animals were randomized to either fluid loading (n = 8, isotonic saline, 1 L/hr for 2 hr) or diuretic treatment (n = 8, furosemide, 40 mg every 30 min, total 160 mg) and compared with a vehicle group (n = 6, no treatment). MEASUREMENTS AND MAIN RESULTS Hemodynamics were evaluated at baseline, after pulmonary embolism and after each dose by biventricular pressure-volume loops, invasive pressures, diuretic output, respiratory variables, and blood analysis. Pulmonary embolism increased mean pulmonary arterial pressure (p < 0.0001), pulmonary vascular resistance (p = 0.008), right ventricular arterial elastance (p = 0.003), and right ventricular end-systolic volume (p = 0.020) while right ventricular stroke volume and right ventricular ejection fraction were decreased (p = 0.047 and p = 0.0003, respectively) compared with baseline. Fluid loading increased right ventricular end-diastolic volume (+31 ± 13 mL; p = 0.004), right ventricular stroke volume (+23 ± 10 mL; p = 0.009), cardiac output (+2,021 ± 956 mL; p = 0.002), and right ventricular ejection fraction (+7.6% ± 1.5%; p = 0.032), whereas pulmonary vascular resistance decreased (-202 ± 65 dynes; p = 0.020) compared with vehicle. Diuretic treatment decreased right ventricular end-diastolic volume (-84 ± 11 mL; p < 0.001), right ventricular stroke volume (-40 ± 6 mL; p = 0.001), cardiac output (-3,327 ± 451 mL; p = 0.005), and mean pulmonary arterial pressure (-7 ± 1 mm Hg; p < 0.001) and increased right ventricular end-systolic elastance (+0.72 ± 0.2 mm Hg/mL; p < 0.001) and systemic vascular resistance (+1,812 ± 767 dynes; p < 0.001) with no effects on mean arterial pressure. CONCLUSIONS In a porcine model of acute intermediate-risk pulmonary embolism, fluid loading increased right ventricular preload and right ventricular stroke volume, whereas diuretics decreased right ventricular preload and right ventricular stroke volume without affecting mean arterial pressure.
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79
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Right ventricular dysfunction is superior and sufficient for risk stratification by a pulmonary embolism response team. J Thromb Thrombolysis 2020; 49:34-41. [PMID: 31375993 DOI: 10.1007/s11239-019-01922-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Several risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). The presence of right ventricular (RV) dysfunction is an independent predictor of mortality and may be a more efficient way to stratify risk for patients assessed by a Pulmonary Embolism Response Team (PERT). We evaluated 571 patients presenting with acute PE, then stratified them by the pulmonary embolism severity index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk/submassive (RV dysfunction by imaging), or high risk/massive PE (RV dysfunction with sustained hypotension). Using imaging data to firstly define the presence of RV strain, and plasma cardiac biomarkers as additional evidence for myocardial dysfunction, we evaluated whether PESI, BOVA, or RV strain by imaging were more appropriate for determining patient risk by a PERT where rapid decision making is important. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% CI 0.73-0.95, p < 0.0001), and 0.88 (95% CI 0.79-0.97, p < 0.0001), respectively. Cardiac TnT and NT-proBNP easily distinguished low risk from massive PE with an area under the curve (AUC) of 0.89 (95% CI 0.78-1.00, p < 0.0001), and 0.89 (95% CI 0.82-0.95, p < 0.0001), respectively. In patients with RV dysfunction, the predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality by a two-fold order of magnitude. The presence of RV dysfunction alone in the context of acute PE is sufficient for the purposes of risk stratification. More complicated risk stratification tools which require the consideration of multiple clinical variables may under-estimate short-term mortality risk.
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80
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Chen YY, Chen YC, Wu CC, Yen HT, Huang KR, Sheu JJ, Lee FY. Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases. J Cardiothorac Surg 2020; 15:295. [PMID: 33008478 PMCID: PMC7532628 DOI: 10.1186/s13019-020-01347-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 01/21/2023] Open
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. Methods Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. Results Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). Conclusions ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.
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Affiliation(s)
- Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan.
| | - Yin-Chia Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Fan-Yen Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
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81
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López-Núñez JJ. Pulmonary embolism treatment. Detection of chronic thromboembolic pulmonary hypertension. Rev Clin Esp 2020; 220:S0014-2565(20)30210-1. [PMID: 32921436 DOI: 10.1016/j.rce.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/19/2020] [Accepted: 07/26/2020] [Indexed: 11/18/2022]
Abstract
The correct stratification of pulmonary embolism risk (PE) is essential for decision-making, regarding treatment and defining the patient's place of admission. In high-risk PE, urgent re-establishment of pulmonary circulation and admission to a critical unit is required. The reperfusion treatment of choice is systemic thrombolysis, although in certain situations, especially when there is a contraindication for it, we will evaluate a surgical embolectomy or one of the catheter-guided therapies. In the rest of PE, the treatment of choice will be anticoagulation. Currently, direct oral anticoagulants have become the treatment of choice for the treatment of PE, due to their better safety profile. However, low molecular weight heparins and subsequently antivitamins K, remain the most used treatment, because they are funded by the public system. In cases of PE with cardiorespiratory arrest and / or cardiogenic shock, whenever available at our center, we must consider the indication of extracorporeal membrane oxygenation. The recent creation of PE response teams (PERT team), have meant an improvement in the care of patients with intermediate-high and high risk PE. During the follow-up of patients with PE, it is essential to perform a correct screening of chronic thromboembolic pulmonary hypertension, in order to perform a correct diagnostic and therapeutic approach.
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Affiliation(s)
- J J López-Núñez
- Servicio de Medicina Interna, Hospital Universitari Germans Trial i Pujol, Badalona,Universidad Autónoma de Barcelona, Badalona, Barcelona, España.
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82
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Choi JH, O’Malley TJ, Maynes EJ, Weber MP, D’Antonio ND, Mellado M, West FM, Galanis T, Gonsalves CF, Marhefka GD, Awsare BK, Merli GJ, Tchantchaleishvili V. Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism. Ann Thorac Surg 2020; 110:1072-1080. [DOI: 10.1016/j.athoracsur.2020.01.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/10/2019] [Accepted: 01/30/2020] [Indexed: 12/18/2022]
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83
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Porres-Aguilar M, Rivera-Lebron BN, Anaya-Ayala JE, León MCGD, Mukherjee D. Perioperative Acute Pulmonary Embolism: A Concise Review with Emphasis on Multidisciplinary Approach. Int J Angiol 2020; 29:183-188. [PMID: 33149540 PMCID: PMC7599112 DOI: 10.1055/s-0040-1709501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Perioperative acute pulmonary embolism represents a relatively rare complication; however, it could be very serious and devastating in some cases. Its diagnosis could be particularly challenging, especially in the intraoperative period. Herein, we emphasize some key concepts with the aim to perform an early and appropriate risk stratification, diagnostic and therapeutic approach in a multidisciplinary fashion, a brief overview on thromboprophylaxis, with the main objective to improve outcomes and survival in these challenging patients.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, McGill University/Centre of Excellence of Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, Montreal, Quebec, Canada
| | - Belinda N. Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Javier E. Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), Ciudad de México, México
| | - María Cristina Guerrero de León
- Department of Internal Medicine and Intensive Care Unit; Hospital de Ginecologia y Obstetricia; UMAE 23; Instituto Mexicano del Seguro Social (IMSS); Monterrey, Mexico
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, El Paso, Texas
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84
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Francis S, Kabrhel C. Current Controversies in Caring for the Critically Ill Pulmonary Embolism Patient. Emerg Med Clin North Am 2020; 38:931-944. [PMID: 32981627 DOI: 10.1016/j.emc.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Department of Surgery, Duke University Hospital, DUH Box 3096, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA. https://twitter.com/chriskabrhel
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85
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Choi SH, Cha SI, Park JE, Park S, Lee YH, Seo H, Yoo SS, Lee SY, Lee J, Kim CH, Park JY. Electrocardiographic changes as a prognostic tool for hospitalized patients with pulmonary embolism. Thromb Res 2020; 192:61-63. [PMID: 32450449 DOI: 10.1016/j.thromres.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Sun Ha Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Seung-Ick Cha
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
| | - Ji-Eun Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sunji Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yong-Hoon Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyewon Seo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Seung-Soo Yoo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Shin-Yup Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Chang-Ho Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae-Yong Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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86
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Kalivoda EJ, Rivera Rodriguez K, Cabrera G. Right Heart Thrombus in Transit Diagnosed With Focused Cardiac Ultrasound in the Emergency Department. Cureus 2020; 12:e9354. [PMID: 32850226 PMCID: PMC7444960 DOI: 10.7759/cureus.9354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The diagnosis of a right heart thrombus (RHTh) in transit associated with pulmonary embolism (PE) is an uncommon phenomenon with a high mortality rate. Timely recognition of RHTh with focused cardiac ultrasound (FOCUS) in cases of suspected PE is necessary for critical decision making in the emergency department (ED). We present a case of RHTh with submassive PE in which the patient underwent successful catheter-directed thrombolysis. This case report illustrates the significance of an emergency physician (EP) implementing FOCUS during the initial ED evaluation to rapidly diagnose RHTh in transit and initiate PE therapy without delay.
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Affiliation(s)
- Eric J Kalivoda
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Kevin Rivera Rodriguez
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Gabriel Cabrera
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
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87
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Brand J, McGowan R, Nimunkar A. Review of pulmonary emboli and techniques for their mechanical removal to inform device design. J Med Eng Technol 2020; 44:255-265. [PMID: 32657668 DOI: 10.1080/03091902.2020.1791985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pulmonary emboli present a significant burden of disease, with limited treatment options for some patients. Mechanical devices for pulmonary emboli removal are becoming increasingly prevalent though more work remains to be done. This paper briefly discusses the mechanical properties of pulmonary emboli, the disease state they cause, and the existing embolectomy devices. The goal of this paper is to aid the design of minimally invasive mechanical pulmonary emboli removal devices, by providing a review of this topic as well as some key design specifications.
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Affiliation(s)
- Jessica Brand
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Roger McGowan
- Research and Development, Boston Scientific, Maple Grove, MN, USA
| | - Amit Nimunkar
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
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88
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Bhalla A, Attaran R. Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices. Tex Heart Inst J 2020; 47:202-206. [PMID: 32997787 DOI: 10.14503/thij-19-7025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies are needed.
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Affiliation(s)
- Aneil Bhalla
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut 06519
| | - Robert Attaran
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut 06519
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89
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Novicic N, Dzudovic B, Subotic B, Shalinger-Martinovic S, Obradovic S. Electrocardiography changes and their significance during treatment of patients with intermediate-high and high-risk pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 9:271-278. [PMID: 30632764 DOI: 10.1177/2048872618823441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Electrocardiography (ECG) signs, typical or acute pulmonary embolism, and their changes can be used for the prediction of clinical and haemodynamic outcomes. PURPOSE To study the predictive value of the resolution of admission ECG signs in higher risk pulmonary embolism patients for 30-day survival and for the decrease in right ventricular systolic pressure. METHODS We analysed the 12-lead ECGs at admission and daily for the first 5 days after hospitalisation in 110 intermediate-high and high-risk pulmonary embolism patients admitted to the intensive care unit of a single tertiary centre. The predictive value of the resolution of four ECG signs were analysed for 30-day survival and for the changes in right ventricular systolic pressure during hospitalisation: S-wave in the first standard lead, right bundle branch block pattern, S-wave in the aVL lead and negative T-waves in precordial leads. RESULTS ECG recordings showed the existence of S-wave in the I lead in 71 (64.5%), S-wave in the aVL in 77 (70%), right bundle branch block pattern in 30 (27.3%) and negative T-waves in 66 (60%) patients. All-cause 30-day in-hospital mortality was 13.6%. Among the ECG signs, only the presence of right bundle branch block at admission was significantly associated with 30-day all-cause mortality (hazard ratio (HR) adjusted for age, gender and right ventricular systolic pressure at admission was 7.7, 95% confidence interval (CI) 2.1-27.9; P=0.002). The resolution of three ECG signs during the first 5 days of hospitalisation, S-wave in the I lead (HR 26.4, 95% CI 3.1-226.6; P=0.003), S-wave in the aVL (HR 21.5, 95% CI 2.6-175.3; P=0.004) and right bundle branch block configuration (HR 5.2, 95% CI 1.3-20.8; P=0.020) were associated with 30-day survival. The intermediate-high and high-risk pulmonary embolism patients with S-wave resolution in lead aVL had 0.0% and 7.1% 30-day all-cause mortality, respectively. The patients with resolution of the S-wave in the first lead and in aVL as well as right bundle branch block had more pronounced changes in right ventricular systolic pressure at discharge (27±13 vs. 13±15 mmHg; P=0.011 for S-wave in I lead resolution, 27±12 vs. 15±17 mmHg; P=0.004 for S-wave in aVL resolution and 23±14 vs. 9±14 mmHg; P=0.040 for right bundle branch block resolution) than patients without resolution. CONCLUSION Resolution of S-waves and right bundle branch block in ECG correlates with lower all-cause 30-day mortality in intermediate-high and high-risk pulmonary embolism patients. Resolution of S-waves in the first lead and in aVL and right bundle branch block correlates with a decrease of right ventricular systolic pressure.
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Affiliation(s)
- Natasha Novicic
- Clinic of Cardiology and Urgent Internal Medicine, Military Medical Academy, Serbia
| | - Boris Dzudovic
- Clinic of Cardiology and Urgent Internal Medicine, Military Medical Academy, Serbia
| | - Bojana Subotic
- Clinic of Cardiology and Urgent Internal Medicine, Military Medical Academy, Serbia
| | | | - Slobodan Obradovic
- Clinic of Cardiology and Urgent Internal Medicine, Military Medical Academy, Serbia.,School of Medicine, University of Defense, Serbia
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90
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Wu H, Cao H, Song Z, Xu X, Tang M, Yang S, Liu Y, Qin L. Rivaroxaban treatment for young patients with pulmonary embolism (Review). Exp Ther Med 2020; 20:694-704. [PMID: 32742315 PMCID: PMC7388139 DOI: 10.3892/etm.2020.8791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
Pulmonary embolism (PE) is a serious, life-threatening condition that affects young populations (>18 and <50 years old, according to most literature reviews) with improved recognition of its clinical manifestations and the widespread use of sensitive imaging techniques, PE is increasingly diagnosed in younger patients. At present, there is limited understanding of the clinical features and adequate anticoagulant treatment options for this population. Most studies to date have yet to demonstrate significant differences in PE pathophysiology or symptoms between young and elderly patients. Although the overall incidence of PE is lower in young populations compared with elderly patients, important risk factors also apply for young patients. Hereditary thrombophilia is common and is a major cause of PE in younger patients. Immobilization, trauma, obesity, smoking and infection are also becoming increasingly frequent in young patients with PE. Among female patients, oral contraceptive use, pregnancy and postpartum status are predominant risk factors underlying PE. Rivaroxaban is a direct oral anticoagulant with a rapid onset of action that is associated with less drug-drug interactions compared with other therapies. Because the drug is administered at fixed doses with no requirement for routine coagulation monitoring, it is becoming an attractive option for anticoagulation treatment in young patients with PE. Therefore, the present literature review focuses on the clinical characteristics of PE and rivaroxaban therapy in younger patients.
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Affiliation(s)
- Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Zikai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Xiaoyan Xu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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91
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Lyhne MD, Schultz JG, Kramer A, Mortensen CS, Nielsen-Kudsk JE, Andersen A. Right ventricular adaptation in the critical phase after acute intermediate-risk pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620925253. [PMID: 32436719 DOI: 10.1177/2048872620925253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The haemodynamic response following acute, intermediate-risk pulmonary embolism is not well described. We aimed to describe the cardiovascular changes in the initial, critical phase 0-12 hours after acute pulmonary embolism in an in-vivo porcine model. METHODS Pigs were randomly allocated to pulmonary embolism (n = 6) or sham (n = 6). Pulmonary embolism was administered as autologous blood clots (20 × 1 cm) until doubling of mean pulmonary arterial pressure or mean pulmonary arterial pressure was greater than 34 mmHg. Sham animals received saline. Cardiopulmonary changes were evaluated for 12 hours after intervention by biventricular pressure-volume loop recordings, invasive pressure measurements, arterial and central venous blood gas analyses. RESULTS Mean pulmonary arterial pressure increased (P < 0.0001) and stayed elevated for 12 hours in the pulmonary embolism group compared to sham. Pulmonary vascular resistance and right ventricular arterial elastance (right ventricular afterload) were increased in the first 11 and 6 hours, respectively, after pulmonary embolism (P < 0.01 for both) compared to sham. Right ventricular ejection fraction was reduced (P < 0.01) for 8 hours, whereas a near-significant reduction in right ventricular stroke volume was observed (P = 0.06) for 4 hours in the pulmonary embolism group compared to sham. Right ventricular ventriculo-arterial coupling was reduced (P < 0.05) for 6 hours following acute pulmonary embolism despite increased right ventricular mechanical work in the pulmonary embolism group (P < 0.01) suggesting right ventricular failure. CONCLUSIONS In a porcine model of intermediate-risk pulmonary embolism, the increased right ventricular afterload caused initial right ventricular ventriculo-arterial uncoupling and dysfunction. After approximately 6 hours, the right ventricular afterload returned to pre-pulmonary embolism values and right ventricular function improved despite a sustained high pulmonary arterial pressure. These results suggest an initial critical and vulnerable phase of acute pulmonary embolism before haemodynamic adaptation.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | | | - Anders Kramer
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | | | - Jens Erik Nielsen-Kudsk
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Asger Andersen
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
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92
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Abstract
Management of pulmonary embolism (PE) has become more complex due to the expanded role of catheter-based therapies, surgical thrombectomies, and cardiac assist technologies, such as right ventricular assist devices and extracorporeal support. Due to the heterogeneity of PE, a multidisciplinary team approach is necessary. The manifestation of PE response teams are in response to this complex need and similar to the proliferation of stroke, trauma, and rapid response teams. Intensive care units are an ideal location for formulating a comprehensive treatment plan that necessitates an interaction between multiple specialties. This article addresses the unique needs of critically ill patients with PE.
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Affiliation(s)
- Michael Baram
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA.
| | - Bharat Awsare
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA
| | - Geno Merli
- Department of Medicine and Surgery, Division of Vascular Medicine, Jefferson University Hospital, 111 South 11th Street Suite 6210, Philadelphia, PA 19107, USA
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93
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Kobayashi S, Muto M, Yabe H, Imao M, Okada Y. A retrospective observational study investigating the factors associated with right heart failure in patients with primary acute pulmonary embolism and deep vein thrombosis. J Gen Fam Med 2020; 21:63-70. [PMID: 32489758 PMCID: PMC7260167 DOI: 10.1002/jgf2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 01/13/2020] [Accepted: 02/04/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The relationship between the risk of right heart failure in primary acute pulmonary embolism after embolization and the residual thrombus sites in the pelvis and lower limbs is not clear. METHODS This single-center retrospective observational study examined the results of contrast-enhanced computed tomography and venous ultrasonography of patients with primary acute PE and DVT. We assessed the association between the occurrence of right heart failure and age; gender; pulmonary thrombosis distribution; most proximal site of deep vein thrombosis in the soleal vein, inferior vena cava (IVC), or common iliac vein (CIV); DVT distribution; and malignancy using univariate and multivariate logistic regression. RESULTS In all, 77 of 165 patients were male (mean age: 65.1 ± 13.7 years). Right heart failure occurred in 53 patients (32.1%). Multivariate analysis revealed that the odds ratio (OR) for right heart failure was significantly lower in patients with the most proximal site of DVT in the IVC/CIV (OR = 0.07, 95% confidence interval [CI] 0.01-0.62, P = .017), while it was significantly higher in females (OR = 2.51, 95% CI 1.05-6.01, P = .039), and in patients who exhibited the presence of bilateral venous thrombosis (OR = 3.89, 95% CI 1.60-9.48, P = .003). CONCLUSION A significant factor involved in PE without right heart failure was the most proximal site of DVT in the IVC/CIV, and significant risk factors associated with PE with right heart failure were more prevalent in females and in patients who exhibited the presence of bilateral venous thrombosis.
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Affiliation(s)
- Satoshi Kobayashi
- Department of RadiologySaitama Rehabilitation CenterAgeoJapan
- Department of RadiologySaitama Cardiovascular Respiratory CenterKumagayaJapan
- Graduate School of Health ScienceSuzuka University of Medical ScienceSuzukaJapan
| | - Makoto Muto
- Division of CardiologySaitama Cardiovascular Respiratory CenterKumagayaJapan
| | - Hitoshi Yabe
- Department of RadiologySaitama Rehabilitation CenterAgeoJapan
- Division of Health SciencesGraduate School of Medical SciencesKanazawa UniversityKanazawaJapan
| | - Masashi Imao
- Graduate School of Health ScienceSuzuka University of Medical ScienceSuzukaJapan
- School of Radiological SciencesFaculty of Health ScienceGunma Paz UniversityTakasakiJapan
| | - Yukinori Okada
- Graduate School of Health ScienceSuzuka University of Medical ScienceSuzukaJapan
- Department of RadiologySt. Marianna University School of MedicineKawasakiJapan
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94
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Au A, Hsu P, McClure M, Cabrera G, Kalivoda EJ. Serial Point-of-care Echocardiography Performed by an Emergency Physician to Guide Thrombolytic Management of Massive Pulmonary Embolism. Cureus 2020; 12:e7771. [PMID: 32461847 PMCID: PMC7243659 DOI: 10.7759/cureus.7771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Massive pulmonary embolism (PE) is a life-threatening condition with a high mortality burden. The rapid diagnosis of PE can be supported with focused cardiac ultrasound (FOCUS) by identifying signs of right ventricular dysfunction (RVD). This case report describes a patient with hemodynamically unstable massive PE who received systemic thrombolytic therapy. Emergency physicians performed serial FOCUS examinations to assess the resolution of RVD in guidance of clinical management.
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Affiliation(s)
- Annie Au
- Emergency Medicine, Hospital Corporation of America West Florida GME Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Patrick Hsu
- Emergency Medicine, Hospital Corporation of America West Florida GME Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Matthew McClure
- Emergency Medicine, Hospital Corporation of America West Florida GME Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Gabriel Cabrera
- Emergency Medicine, Hospital Corporation of America West Florida GME Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Eric J Kalivoda
- Emergency Medicine, Hospital Corporation of America West Florida GME Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
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95
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Lee YH, Cha SI, Kim H, Kim CY, Choi SH, Seo H, Yoo SS, Lee SY, Lee J, Kim CH, Park JY. Clinical characteristics and outcome in patients with pulmonary embolism undergoing coronary angiography. Vasc Med 2020; 25:157-159. [DOI: 10.1177/1358863x19900239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yong-Hoon Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Seung-Ick Cha
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chang-Yeon Kim
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Sun Ha Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Hyewon Seo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Seung-Soo Yoo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Shin-Yup Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Chang-Ho Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Jae-Yong Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
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96
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Inui T, Ishida K, Kohno H, Matsuura K, Ueda H, Tamura Y, Watanabe M, Inage Y, Yakita Y, Matsumiya G. Pulmonary Embolectomy for Acute Pulmonary Embolism: A Word of Caution. Ann Vasc Dis 2020; 13:96-99. [PMID: 32273932 PMCID: PMC7140157 DOI: 10.3400/avd.cr.19-00089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pulmonary embolectomy is an effective treatment of acute pulmonary embolism (APE) but not for chronic pulmonary thromboembolism. We described surgical experience of two patients with APE in preexistent unidentified chronic pulmonary thromboembolism. One patient who presented with severe hypoxia but stable hemodynamics underwent successful pulmonary endarterectomy for proximal organized thrombus instead of pulmonary embolectomy. The other patient who required extracorporeal membrane oxygenation for severe hypoxia developed right heart failure because of residual distal organized thrombus after pulmonary embolectomy. Clinical and radiographical presentation of APE in chronic pulmonary thromboembolism mimics APE, and thus, candidates of pulmonary embolectomy should be carefully selected.
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Affiliation(s)
- Tomohiko Inui
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Hideki Ueda
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Yusaku Tamura
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Yuichi Inage
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Yasunori Yakita
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Chiba, Japan
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97
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Salinger-Martinovic S, Dimitrijevic Z, Stanojevic D, Momčilović S, Kostic T, Koracevic G, Subotic B, Dzudovic B, Stefanovic B, Matijasevic J, Miric M, Markovic-Nikolic N, Nikolic M, Miloradovic V, Kos L, Kovacevic-Preradovic T, Srdanovic I, Stanojevic J, Obradovic S. Renal dysfunction as intrahospital prognostic indicator in acute pulmonary embolism. Int J Cardiol 2020; 302:143-149. [DOI: 10.1016/j.ijcard.2019.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/08/2019] [Accepted: 12/12/2019] [Indexed: 11/26/2022]
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98
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Hong B, Yoon SH, Park SY, Song S, Youn A, Hwang JG. Cardiac Arrest from Patient Position Change after Spine Surgery on a Jackson Table. Acute Crit Care 2019; 34:86-91. [PMID: 31723910 PMCID: PMC6849050 DOI: 10.4266/acc.2016.00794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/06/2016] [Accepted: 10/10/2016] [Indexed: 11/30/2022] Open
Abstract
The Jackson table has minimal effects on cardiac function because it does not elevate abdominal and thoracic pressures. In addition, it decreases venous congestion and increases exposure of the surgical field. However, the hips and knees are flexed with inappropriate padding, and venostasis is promoted and increased. Pulmonary thromboembolism (PTE) is fatal; thus immediate diagnosis and treatment are essential. However, clinical signs of intraoperative PTE are difficult to discern. Thrombolytic therapy can be considered as first-line therapy, but bleeding limits its use. The authors report a case of PTE resulting from patient positional change after spine surgery, and the use of immediate postoperative recombinant tissue-type plasminogen activator.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seok Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Soo-Yong Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seunghyun Song
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ann Youn
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ja Gyung Hwang
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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99
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Quezada A, Jiménez D, Bikdeli B, Moores L, Porres-Aguilar M, Aramberri M, Lima J, Ballaz A, Yusen RD, Monreal M. Systolic blood pressure and mortality in acute symptomatic pulmonary embolism. Int J Cardiol 2019; 302:157-163. [PMID: 31761399 DOI: 10.1016/j.ijcard.2019.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/20/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The optimal cutoff for systolic blood pressure (SBP) level to define high-risk pulmonary embolism (PE) remains to be defined. METHODS To evaluate the relationship between SBP levels on admission and mortality in patients with acute symptomatic PE, the current study included 39,257 consecutive patients with acute symptomatic PE from the RIETE registry between 2001 and 2018. Primary outcomes included all-cause and PE-specific 30-day mortality. Secondary outcomes included major bleeding and recurrent venous thromboembolism (VTE). RESULTS There was a linear inverse relationship between admission SBP and 30-day all-cause and PE-related mortality that persisted after multivariable adjustment. Patients in the lower SBP strata had higher rates of all-cause death (reference: SBP 110-129 mmHg) (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI], 2.0-4.2 for SBP <70 mmHg; and OR 1.7; 95% CI, 1.4-2.1 for SBP 70-89 mmHg). The findings for 30-day PE-related mortality were similar (adjusted OR 4.4; 95% CI, 2.7-7.2 for SBP <70 mmHg; and OR 2.6; 95% CI, 1.9-3.4 for SBP 70-89 mmHg). Patients in the higher strata of SBP had significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR 0.7; 95% CI, 0.5-0.9 for SBP 170-190 mmHg; and OR 0.6; 95% CI, 0.4-0.9 for SBP >190 mmHg). Consistent findings were also observed for 30-day PE-related death. CONCLUSIONS In patients with acute symptomatic PE, a low SBP portends an increased risk of all-cause and PE-related mortality. The highest mortality was observed in patients with SBP <70 mmHg.
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Affiliation(s)
- Andrés Quezada
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain.
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Lisa Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, USA
| | - Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, Center of Excellence in Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Mario Aramberri
- Department of Medicine, Hospital Doce de Octubre, Madrid, Spain
| | - Jorge Lima
- Respiratory Department of Medicine, Hospital Universitario Nuestra Señora de Valme, Sevilla, Spain
| | - Aitor Ballaz
- Respiratory Department, Hospital Galdakao, Galdakao, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Universidad Católica de Murcia, Murcia, Spain
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100
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Kotsiou OS, Karadontas V, Daniil Z, Zakynthinos E, Gourgoulianis KI. Transcutaneous carbon dioxide monitoring as a predictive tool for all-cause 6-month mortality after acute pulmonary embolism. Eur J Intern Med 2019; 68:44-50. [PMID: 31416659 DOI: 10.1016/j.ejim.2019.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/27/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) frequently remains undiagnosed. The partial pressure of carbon dioxide (PaCO2), a surrogate of dead-space ventilation, is useful in the evaluation of the degree of pulmonary artery occlusion. At present, there is no knowledge about the prognostic role of PaCΟ2 variations during the first hours of an acute PE. Transcutaneous measurement of CO2 (PtcCO2) is a simple, non-invasive method that correlates well with PaCO2 levels, evaluated in this study for the first time in patients with PE. PURPOSE To assess the correlation between PtcCO2 and PaCO2 levels in the acute phase of PE and the role of PtcCO2 in predicting 6-months mortality. METHODS This was a pilot study including 53 patients with acute PE who hospitalized in Respiratory Medicine Department at University Hospital of Larissa in central Greece during 15 months. PtcCO2 was constantly monitored for four hours after PE diagnosis with the TCM40 monitoring system (SmartCal). Simultaneous arterial blood gas measurements were performed. Each patient was prospectively recorded for six months via standard telephone calls. RESULTS PaCO2 and PtcCO2 values were well-correlated in the acute phase of PE. Decreased PtcCO2 levels in the first monitoring hour were associated with a higher risk of mortality. In the PE subgroup who died, the lower PtcCO2 level in the first hour of PE was a predictor of shorter survival time independently of gender, age, comorbidities, and smoking status. CONCLUSION PtcCO2 measurement, especially in the first hour after PE, seemed to be a valid tool in predicting all-cause 6-month mortality.
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Affiliation(s)
- Ourania S Kotsiou
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece.
| | - Vasileios Karadontas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece
| | - Zoe Daniil
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece
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