Spectral Detector Computed Tomography Pulmonary Angiography: Improved Diagnostic Assessment and Automated Estimation of Window Settings Angiography of Pulmonary Arteries From Novel Spectral Detector Computed Tomography Provides Improved Image Quality if Settings are Adjusted

OBJECTIVE

This study aimed to evaluate image quality (IQ) of virtual monoenergetic images (VMIs) from novel spectral detector computed tomography angiography of the pulmonary arteries and to identify appropriate window settings for each kiloelectron volt level.

MATERIALS

Forty consecutive patients were included in this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study.Signal- and contrast-to-noise ratios were calculated within the pulmonary trunk, and pulmonary/lobar/segmental arteries were calculated. The IQ and diagnostic certainty were rated by 2 radiologists on 5-point scales. In addition, they recorded appropriate window settings (center/width) that were linearly modeled against attenuation within the pulmonary trunk to generate generable results.

RESULTS

Signal- and contrast-to-noise ratios, IQ, and diagnostic certainty are significantly increased in low-kiloelectron volt VMIs (≤60 keV). Interrater agreement was excellent (ĸ = 0.89). We developed 2 linear models (R: 0.91-0.97 and R: 0.43-0.91, respectively, P ≤ 0.01), that suggest appropriate window settings.

CONCLUSIONS

The VMIs from spectral detector computed tomography improve objective and subjective IQ in angiography of the pulmonary arteries, if window settings are adjusted; they can be automatically estimated using reported linear models.

Treatment of submassive and massive pulmonary embolism: a clinical practice survey from the second annual meeting of the Pulmonary Embolism Response Team Consortium

There is a paucity of robust clinical trial data to guide the treatment of acute pulmonary embolism (PE) thus the clinical guidelines rely heavily on expert opinion. Pulmonary Embolism Response Teams (PERT) have been developed to streamline the care of patients with acute PE. We conducted a survey among 100 experts in the field of PE during the second annual meeting of the PERT Consortium. Respondents were queried with respect to their demographic information, clinical practice questions and clinical vignettes. Clinical practice questions were focused questions about the risk stratification and treatment of patients with acute submassive PE, anticoagulation strategies for patients receiving thrombolysis and the use of inferior vena cava filters. Clinical vignettes were designed to assess participants' preferred choice of treatment for a variety of commonly encountered clinical scenarios. Among physicians affiliated with a PERT, there is overall agreement with regards to the criteria used for risk classification of patients with PE and its application to patients in the provided clinical vignettes. In contrast, there is substantial variability in the treatment strategies of patients presenting with commonly encountered clinical scenarios. The results of this survey highlight the need for more clinical trial data along with accepted algorithms for treatment of acute PE. In the absence of this, PERTs can facilitate multidisciplinary discussions in order to standardize treatment and provide evidence-based therapies to patients with acute PE.

[Medicinal treatment of tricuspid valve regurgitation]

The vast majority of tricuspid valve regurgitations are of low degree without prognostic relevance in healthy individuals; however, morbidity and mortality increase with the degree of regurgitation, which can be secondary to either primary (structural) or secondary (functional) alterations of the valve. Due to the frequent lack of symptoms, echocardiographic examinations should be annually performed in patients with higher degree (at least moderate) tricuspid valve regurgitation, in particular in the presence of risk factors. Individual therapeutic management strategies should consider the etiology of the tricuspid valve regurgitation, the degree of regurgitation, the valve pathology and the risk-to-benefit ratio of the envisaged therapeutic procedure. Medicinal treatment options for tricuspid valve regurgitation are limited and generalized recommendations cannot be provided due to the lack of conclusive clinical trials. Symptomatic therapeutic measures encompass especially (loop) diuretics for the reduction of preload and afterload of the right ventricle. Pharmaceutical reduction of the heart rate should be avoided in patients with right heart insufficiency. While symptomatic therapeutic measures are often associated with only moderate effects, the most effective therapy of tricuspid valve regurgitation consists in the treatment of underlying illnesses, in most cases pulmonary hypertension due to pulmonary arterial hypertension (PAH), left heart disease or acute pulmonary embolism. Based on a number of published clinical studies and licensing of new drugs, treatment options for patients with PAH and heart failure with reduced ejection fraction (HFrEF) have substantially improved during the past years allowing for a differentiated, individualized management.

Association of the CYP4V2 polymorphism rs13146272 with venous thromboembolism in a Chinese population

Genome-wide association studies have identified the CYP4V2 polymorphism (rs13146272) as a risk factor associated with venous thromboembolism (VTE). However, due to the small sample size and variance in genetic analysis models, the relationship between VTE and rs13146272 remains unclear. Here, we performed a case-control study to analyse the associations between rs13146272 and VTE in a Chinese population and to compare the differences among various ethnicities. In this study, 226 VTE patients and 205 healthy controls were recruited, and the allele frequency of variant rs13146272 was analysed by a MassARRAY SNP genotyping assay. In addition, 9 case-control cohorts from 5 studies involving 6667 VTE-affected individuals and 8716 control subjects were included in this meta-analysis. Pooled ORs and 95% CIs were calculated to assess the association between rs13146272 and VTE by using different genetic models. Our case-control study results showed that there was no significant association between VTE and rs13146272 under the additive model (OR = 0.92, 95% CIs: 0.70-1.21, p = 0.55) in this Chinese population. However, the results of the meta-analysis performed by merging all cohorts showed that rs13146272 was significantly associated with VTE under the additive model, recessive model and dominant model. In the additive and recessive models, the association reached the threshold for genome-wide significance (p < 5.0e^-08). In conclusion, our pooled systematic study results indicated that individuals with the A allele had a higher risk of developing VTE than those with the C allele of the rs13146272 variant, but the risk was inconsistent among different ethnicities. Further validation of this association with larger sample sizes and multiple ethnicities is warranted.

Validation of simplified PESI score for identification of low-risk patients with pulmonary embolism: From the COMMAND VTE Registry

Background:

The simplified pulmonary embolism severity index (sPESI) score has been reported to be useful in predicting 30-day mortality for patients with pulmonary embolism, which helps the identification of low-risk patients for early hospital discharge or home treatment. However, therapeutic decision-making should also be based on the risks of adverse events other than mortality.

Methods:

The COMMAND VTE Registry is a multicentre registry enrolling consecutive patients with acute symptomatic venous thromboembolism in Japan between January 2010 and August 2014, and the current study population consisted of 1715 patients with pulmonary embolism. We calculated the sPESI score for each patient, and compared 30-day rates of mortality, recurrent venous thromboembolism and major bleeding between sPESI scores of 0 and 1 or greater.

Results:

Patients with a sPESI score of 0 accounted for 383 (22%) patients, and 110 (6.4%) patients died within 30 days. The cumulative 30-day incidence of mortality was lower in patients with a sPESI score of 0 than those with a sPESI score of 1 or greater (0.5% vs. 8.1%, log rank P<0.001). There was no significant difference in the cumulative 30-day incidence of recurrent venous thromboembolism between patients with a sPESI score of 0 and 1 or greater (1.3% vs. 2.8%, log rank P=0.11). The cumulative 30-day incidence of major bleeding was lower in patients with a sPESI score of 0 than those with a sPESI score of 1 or greater (1.1% vs. 4.0%, log rank P=0.005).

Conclusions:

In patients with a sPESI score of 0, the 30-day mortality, recurrent venous thromboembolism and major bleeding rates were reasonably low. The sPESI score could be useful to identify candidates for early hospital discharge or home treatment.

A new method of CT for the cardiac measurement: correlation of computed tomography measured cardiac parameters and pulmonary obstruction index to assess cardiac morphological changes in acute pulmonary embolism patients

Acute pulmonary embolism (APE) is a serious disease which is life-threatening. Since it is crucial for APE patients to assess the changes of cardiac function safely and timely, the imaging research of cardiac morphology and function is becoming more and more important. The correlation of computed tomography (CT) measured cardiac parameters and pulmonary obstruction index (POI) was analyzed to discuss the morphological changes of the heart of APE patients in order to provide a new method to evaluate cardiac functions accurately and effectively. 118 APE patients confirmed with CT pulmonary angiography (CTPA) were divided into high-risk group (47 cases, POI ≥ 20) and low-risk group (71 cases, POI < 20) according to the Qanadli Score. The left to right diameter (RL) and the anteroposterior diameter (AP) of the cardiac chambers were compared among the high-risk group, the low-risk group, and the normal group (60 cases). The correlation between CT measured cardiac parameters and the POI was analyzed. Except for left ventricular AP and right atrial AP, there were statistically significant differences (P < 0.05) in the RL and AP of the each cardiac cavity, these parameters meant that right hearts were enlarged and the left hearts were decreased in size. The ratio of right/left heart diameter was statistically significant among the three groups, a < b < c (P < 0.05). Moreover, the POI of 118 APE patients was 14.29 ± 9.53, and there was significant linear correlation between CT measured cardiac parameters and the POI (P < 0.05), excluding the left ventricular AP and right atrial AP. The correlation coefficient reached 0.5 or more in terms of the right atrial LR, the right ventricular LR, the ratio of right/left atrial diameter and the ratio of right/left ventricular diameter. With the increasing value of POI, the right atrium and right ventricular of APE patients were enlarged, and the left atrium and left ventricular were decreased in size. These heart changes can be observed by using CTPA, even non-enhanced chest CT.

COSIMO - patients with active cancer changing to rivaroxaban for the treatment and prevention of recurrent venous thromboembolism: a non-interventional study

BACKGROUND

Around 20% of venous thromboembolism (VTE) cases occur in patients with cancer. Current guidelines recommend low molecular weight heparin (LMWH) as the preferred anticoagulant for VTE treatment. However, some guidelines state that vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) are acceptable alternatives for long-term therapy in some patients if LMWHs are not available. LMWHs and VKAs have a number of drawbacks that can increase the burden on patients. DOACs, such as rivaroxaban, can ameliorate some burdens and may offer an opportunity to increase patient satisfaction and health-related quality of life (HRQoL). The Cancer-associated thrOmboSIs - patient-reported outcoMes with rivarOxaban (COSIMO) study is designed to provide real-world information on treatment satisfaction in patients with active cancer who switch from LMWH or VKA to rivaroxaban for the treatment of acute VTE or to prevent recurrent VTE.

METHODS

COSIMO is a prospective, non-interventional, single-arm cohort study that aims to recruit 500 patients in Europe, Canada and Australia. Adults with active cancer who are switching to rivaroxaban having received LMWH/VKA for the treatment and secondary prevention of recurrent VTE for at least the previous 4 weeks are eligible. Patients will be followed for 6 months. The primary outcome is treatment satisfaction assessed as change in the Anti-Clot Treatment Scale (ACTS) Burdens score at week 4 after enrolment compared with baseline. Secondary outcomes include treatment preferences, measured using a discrete choice experiment, change in ACTS Burdens score at months 3 and 6, and change in HRQoL (assessed using the Functional Assessment of Chronic Illness Therapy - Fatigue questionnaire). COSIMO will collect data on patients' medical history, patterns of anticoagulant use and incidence of bleeding and thromboembolic events. Study recruitment started in autumn 2016.

CONCLUSIONS

COSIMO will provide information on outcomes associated with switching from LMWH or VKA therapy to rivaroxaban for the treatment or secondary prevention of cancer-associated thrombosis in a real-life setting. The key goal is to assess whether there is a change in patient-reported treatment satisfaction. In addition, COSIMO will facilitate the evaluation of the safety and effectiveness of rivaroxaban in preventing recurrent VTE in this patient population.

TRIAL REGISTRATION

NCT02742623. Registered 19 April 2016.

Prise en charge de l'embolie pulmonaire grave en réanimation

L'embolie pulmonaire (EP) grave, définie par la présence d’un état de choc, est à l'origine d'une mortalité importante. L'objectif de cette mise au point est de synthétiser les dernières avancées et recommandations concernant la prise en charge des formes graves d'EP. La stratification du risque individuel de mortalité précoce permet d'apporter une stratégie diagnostique et thérapeutique optimisée pour chaque patient. Le traitement symptomatique consiste essentiellement en la prise en charge de l'état de choc. L'anticoagulation curative par héparine non fractionnée est réservée aux patients hémodynamiquement instables. Chez ces patients à haut risque, la thrombolyse systémique diminue la mortalité et le risque de récidive d'EP. Chez les patients à risque intermédiaire élevé, la thrombolyse systémique à dose standard diminue le risque de choc secondaire mais sans impact sur la mortalité globale. La thrombolyse est donc réservée aux patients à risque intermédiaire élevé présentant secondairement un état de choc. L'embolectomie chirurgicale reste indiquée en cas de contre-indication absolue à la thrombolyse ou en cas d'échec de celle-ci. Le positionnement dans l'algorithme thérapeutique de l'assistance extracorporelle et des techniques percutanées de revascularisation reste à définir. Leurs indications doivent donc être discutées dans des centres experts après une concertation multidisciplinaire incluant pneumologues, cardiologues, réanimateurs, radiologues interventionnels et chirurgiens cardiaques.

External validation of three risk stratification rules in patients presenting with pulmonary embolism and cancer

Numerous risk stratification rules exist to predict post-pulmonary embolism (PE) mortality; however, few were designed for use in cancer patients. In the EPIPHANY registry, adapted versions of common rules (the Hestia criteria, Pulmonary Embolism Severity Index [PESI], and simplified PESI [sPESI]) displayed high sensitivity for prognosticating mortality in PE patients with cancer. These adapted rules have yet to be externally validated. Therefore, we sought to evaluate the performance of an adapted Hestia criteria, PESI, and sPESI for predicting 30-day post-PE mortality in patients with cancer. We identified consecutive, adults presenting with objectively confirmed PE and cancer to our institution (November 2010 to January 2014). The proportion of patients categorized as low or high risk by these three risk stratification rules was calculated, and each rule's accuracy for predicting 30-day all-cause mortality was determined. Of the 124 patients with PE and active cancer identified, 25 (20%) experienced mortality at 30 days. The adapted Hestia criteria categorized 23 (19%) patients as low risk, while exhibiting a sensitivity of 88% (95% confidence interval [CI] = 68-97%), a negative predictive value NPV of 87% (95% CI = 65-97%), and a specificity of 20% (95% CI = 13-30%). A total of 38 (31%) and 30 (24%) patients were low risk by the adapted PESI and sPESI, with both displaying sensitivities of 92% and NPVs > 93%. Specificities were 36% (95% CI = 27-47%) and 28% (95% CI = 20-38%) for PESI and sPESI. In our external validation, the adapted Hestia, PESI, and sPESI demonstrated high sensitivity but low specificity for 30-day PE mortality in patients with cancer. Larger, prospective trials are needed to optimize strategies for risk stratification in this population.

The impact of a multi-specialty team for high risk pulmonary embolism on resident and fellow education

The impact of the Pulmonary Embolism Response Team (PERT) model on trainee physician education and autonomy over the management of high risk pulmonary embolism (PE) is unknown. A resident and fellow questionnaire was administered 1 year after PERT implementation. A total of 122 physicians were surveyed, and 73 responded. Even after 12 months of interacting with the PERT consultative service, and having formal instruction in high risk PE management, 51% and 49% of respondents underestimated the true 3-month mortality for sub-massive and massive PE, respectively, and 44% were unaware of a common physical exam finding in patients with PE. Comparing before and after PERT implementation, physicians perceived enhanced confidence in identifying ( p<0.001), and managing ( p=0.003) sub-massive/massive PE, enhanced confidence in treating patients appropriately with systemic thrombolysis ( p=0.04), and increased knowledge of indications for systemic thrombolysis and surgical embolectomy ( p=0.043 and p<0.001, respectively). Respondents self-reported an increased fund of knowledge of high risk PE pathophysiology (77%), and the perception that a multi-disciplinary team improves the care of patients with high risk PE (89%). Seventy-one percent of respondents favored broad implementation of a PERT similar to an acute myocardial infarction team. Overall, trainee physicians at a large institution perceived an enhanced educational experience while managing PE following PERT implementation, believing the team concept is better for patient care.

Adenosine 5'-triphosphate's role in bradycardia and syncope associated with pulmonary embolism

Adenosine 5′-triphiosphate (ATP) is released from cells under physiologic and pathophysiologic conditions. Extracellular ATP acts as an autocrine and paracrine agent affecting various cell types by activating cell surface P2 receptors (P2R), which include trans-cell membrane cationic channels, P2XR, and G protein coupled receptors, P2YR. We have previously shown that ATP stimulates vagal afferent nerve terminals in the lungs by activating P2X2/3R. This action could lead to bronchoconstriction, cough and the local release of pro-inflammatory neuropeptides. In addition, ATP markedly enhances the IgE-dependent histamine release from human lung mast cells. Thus, we have proposed for the first time that extracellular ATP plays a mechanistic role in pulmonary pathophysiology in general and chronic obstructive pulmonary disease (COPD), and acute bronchoconstriction in asthma in particular. The present review examines whether ATP could also play a role in bradycardia and syncope in a subset of patients with pulmonary embolism.

Efficacy of Oral Factor Xa Inhibitor for Venous Thromboembolism in a Patient with Antithrombin Deficiency

A 19-year-old man was referred due to sudden onset of right foot pain and chest discomfort. Contrast-enhanced computed tomography revealed massive thrombi in the right pulmonary artery and femoral vein. The patient's father had experienced multiple recurrences of venous thromboembolism (VTE) and was diagnosed with inherited antithrombin deficiency by a genetic examination. The patient was administered the oral factor Xa inhibitor rivaroxaban (30 mg). After seven days, the thrombus disappeared. Rivaroxaban (15 mg) was continued for 6 months with no recurrence, indicating the efficacy of this factor Xa inhibitor for the treatment and prevention of VTE in patients with antithrombin deficiency.

Comprehensive evaluation of the effectiveness and safety of balloon pulmonary angioplasty for inoperable chronic thrombo-embolic pulmonary hypertension: long-term effects and procedure-related complications

Aims

Although balloon pulmonary angioplasty (BPA) improves haemodynamics and short-term prognosis in patients with inoperable chronic thrombo-embolic pulmonary hypertension (CTEPH), the long-term effects of BPA, and procedure-related complications remain to be fully elucidated.

Methods and results

From July 2009 to October 2016, we performed a total of 424 BPA sessions in 84 consecutive patients with inoperable CTEPH. We used 3D reconstructed computed tomography to determine target lesions of pulmonary arteries and optical computed tomography to select balloon size, if needed. In 77 patients (92%) who completed the BPA treatment [65 ± 14 (SD) years-old, male/female 14/63], haemodynamics and exercise capacity were examined at 6 months after last BPA and in the chronic phase [>12 months after first BPA, 31 (20, 41) months]. The BPA treatment significantly improved mean pulmonary arterial pressure (38 ± 10 to 25 ± 6 mmHg), pulmonary vascular resistance (7.3 ± 3.2 to 3.8 ± 1.0 Wood units), and 6-minute walk distance (380 ± 138 to 486 ± 112 m) (all P < 0.01), and the improvements persisted throughout the follow-up period (43 ± 27 months) (N = 53). In the 424 sessions, haemoptysis was noted in 60 sessions (14%), and non-invasive positive pressure ventilation (NPPV) was used to treat haemoptysis and/or hypoxemia in 33 sessions (8%). Furthermore, 5-year survival was 98.4% (only one patient died of colon cancer) with no peri-procedural death.

Conclusion

These results indicate that BPA improves haemodynamics and exercise capacity in inoperable CTEPH patients with acceptable complication rate and that the beneficial haemodynamic effects of BPA persist for years with resultant good long-term prognosis.

Local low-dose urokinase thrombolysis for the management of haemodynamically stable pulmonary embolism with right ventricular dysfunction

AIMS

The aim of this study was to evaluate the effectiveness of local low-dose urokinase thrombolysis (LLDUT) in haemodynamically stable pulmonary embolism with right ventricular dysfunction (RVD).

METHODS AND RESULTS

This was a prospective study. LLDUT with a 200,000 IU bolus followed by a 100,000 IU/hr infusion was given. Treatment duration was determined through radiological control performed 48-72 hrs into treatment. A follow-up echocardiogram was performed within seven days after LLDUT completion. Evolution of thrombus burden, pulmonary artery pressures (PAP) and RVD were studied, and haemorrhagic complications and mortality were recorded. Eighty-seven patients were included (62.5±16.5 years). In 67 patients (77%), the baseline echocardiogram showed mild-to-severe RVD, a dilated right ventricle (diameter: 44.4±6.2 mm) and a decreased tricuspid annular plane systolic excursion (14 mm [12-17]). Seventy-six patients (87.4%) experienced radiological improvement. Initially high PAP (mmHg) decreased after LLDUT: systolic 52.4 vs. 35.2 (17.2 [95% CI: 14.5-19.9]; p<0.0001), mean 34.2 vs. 23.5 (10.7 [95% CI: 9.0-12.5]; p<0.0001) and diastolic 23.9 vs. 16.0 (7.9 [95% CI: 6.1-9.7]; p<0.0001). Follow-up echocardiography showed overall improvement of RVD. No life-threatening haemorrhagic complications were reported. Six-month survival was 96.5%.

CONCLUSIONS

LLDUT rapidly decreased thrombus burden and PAP, improving right ventricular function, and was not associated with any life-threatening complications or pulmonary embolism (PE)- or treatment-related mortality.

Early thrombolytic failure in a patient with massive pulmonary embolism combined with multiple organ dysfunction syndrome: what next?

Carbon monoxide (CO) poisoning, the most frequent type of poisoning, alters hemodynamics and creates tissue hypoxia that ultimately leads to thromboembolism. We herein describe a previously healthy 17-year-old male patient who developed acute CO poisoning while bathing in the same room as a gas heater. He was first treated with urokinase thrombolytic therapy at a local hospital, which proved ineffective. The patient was admitted to our hospital with unstable circulation and was diagnosed with massive pulmonary embolism combined with multiple organ dysfunction syndrome. His Acute Physiology and Chronic Health Evaluation II score was 22, and his Sequential Organ Failure Assessment score was 15. We faced a difficult decision regarding whether to perform surgical embolectomy or to repeat the thrombolysis. We opted to repeat the thrombolysis with successful results. Our experience may help clinicians manage similar cases in the future.

Reperfusion in acute pulmonary thromboembolism

Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.

Prognostic role of neutrophils to lymphocytes ratio in patients with acute pulmonary embolism: a systematic review and meta-analysis of the literature

The prognostic assessment of patients with acute pulmonary embolism (PE) is essential to drive its management. The search for new prognostic factors is a central issue for a more accurate estimate of short-term adverse events. Circulating neutrophils/lymphocytes ratio (NLR) has been suggested as prognostic biomarker for different cardiovascular diseases. Given the central role of inflammation, and in particular of neutrophils in the pathogenesis of VTE and its clinical history, NLR might represent a prognostic tool also in this setting. We performed a systematic review and meta-analysis of the literature to assess the prognostic role of NLR in patients with acute PE. MEDLINE and EMBASE were searched up to 2017, week 21. A bivariate random-effects regression approach was used to obtain summary estimate of accuracy of the high NLR adjusting for inter-study variability. Six studies for a total of 1424 patient are included. High NLR has a weighted mean sensitivity of 77% (95% CI 68-83) and a weighted mean specificity of 74% (95% CI 68-79). High NLR positive and negative predictive values are 24.4% (95% CI 20.4-28.3) and 96.7% (95% CI 95.6-97.8), respectively. The relevant impact of NLR on short-term mortality after an acute PE makes it a promising biomarker to better stratify patient prognosis.

E/E' and D-shaped Left Ventricle Severity in Patients with Increased Pulmonary Artery Pressure

BACKGROUND

D-shaped left ventricle (D-LV) is an interesting echocardiographic finding in pulmonary hypertension (PH) and is the result of structural distortion of the interventricular septum. The eccentricity index (EI) is a quantitative measure used to evaluate the severity of D-LV in patients with increased pulmonary artery pressure (PAP). However, D-LV and EIs have rarely been studied in terms of their association with hemodynamic factors.

METHODS

A total of 526 patients with a maximal tricuspid regurgitation velocity (VmaxTR) > 2.8 m/s on echocardiography identified between January 2012 and December 2017 were enrolled. After exclusion, a total of 289 patients were analyzed. The association between D-LV and hemodynamic factors were analyzed using logistic regression. Furthermore, factors that impacted the severity of the D-LV, as defined by EIs, were also analyzed using the multiple linear regression model.

RESULTS

In the multivariate logistic regression model, higher pulmonary artery pressure (PAP, p = 0.001), lower tricuspid annular plane systolic excursion (TAPSE, p = 0.048), and E/E' (p = 0.017) were found to be significant risk factors for the presence of D-LV. Additional analysis with age and body mass index added to independent variables, PAP (p = 0.008), TAPSE (p = 0.028), and age (p < 0.001) were significant risk factors for the presence of D-LV. In patients with D-LV, only E/E' was independently associated with EIs (R2 = 0.666, p < 0.001).

CONCLUSIONS

In patients with increased PAP, D-LV is associated with PAP, TAPSE, E/E', and age. EIs are associated with left ventricular filling pressure, represented as E/E'.

Acute Heart Failure Management

Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p < 0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p < 0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p = 0.06 vs cardiac US). Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

Prognostic value of cardiovascular parameters in computed tomography pulmonary angiography in patients with acute pulmonary embolism

The value of various computed tomography parameters for prognosis and risk stratification in acute pulmonary embolism is controversial. Our objective was to evaluate the impact of specific cardiovascular computed tomography pulmonary angiography parameters on short- and long-term clinical outcomes.

We analysed radiological and clinical data of 1950 patients with acute pulmonary embolism who participated in an international randomised clinical trial on anticoagulants. Parameters included right/left ventricular ratio, septal bowing, cardiothoracic ratio, diameters of pulmonary trunk and aorta, and intrahepatic/azygos vein contrast medium backflow. Associations with mortality, recurrent venous thromboembolism (VTE), hospitalisation, bleeding and adverse events were assessed over the short term (1 week and 1 month) and long term (12 months).

Pulmonary trunk enlargement was the only parameter significantly associated with mortality over both the short and long term (OR 4.18 (95% CI 1.04–16.76) at 1 week to OR 2.33 (95% CI 1.36–3.97) after 1 year), as well as with recurrent VTE and hospitalisation.

Most of the evaluated radiological parameters do not have strong effects on the short- or long-term outcome in patients with acute pulmonary embolism. Only an enlarged pulmonary trunk diameter carries an increased risk of mortality and recurrent VTE up to 12 months, and can be used for risk stratification.

Pulmonary embolism

Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.

Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper

INTRODUCTION

This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors.

RESULTS

The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.

[Recognizing rare cardiac diseases by electrocardiogram]

A number of rare cardiac diseases can be recognized by electrocardiogram (ECG). This article illustrates the clinical importance of ECG as a key diagnostic tool to detect Wolff-Parkinson-White syndrome and channelopathies, which are frequently diagnosed late after one or more affected family members have become victims of sudden cardiac death. These channelopathies include long QT syndrome, short QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia. In addition, typical ECG findings are frequently present in patients with idiopathic ventricular tachycardia, arrhythmogenic right ventricular dysplasia, digitalis intoxication, hyperkalemia, acute cor pulmonale due to pulmonary embolism, as well as severe left ventricular hypertrophy as in hypertrophic cardiomyopathy.

[Anticoagulation in patients with chronic kidney disease : Recommendations from the working group "Heart-Kidney" of the German Cardiac Society and the German Society of Nephrology]

Indications for anticoagulation are thromboembolic events, prosthetic heart valves, and atrial fibrillation with a corresponding risk score. Clinical trials have excluded patients with advanced chronic kidney disease and these data cannot be always generalized to patients with chronic kidney disease. Non-vitamin K antagonist oral anticoagulants (NOACs) are mostly not recommended or are contraindicated in advanced stages of chronic kidney disease. Observational studies have shown that dialysis patients with atrial fibrillation do not profit from coumarin anticoagulants; prospective studies are lacking.

[Anticoagulation-direct oral anticoagulants]

Since direct oral anticoagulants (DOAC) have become available, use of anticoagulant treatment has become easier and safer-for patients suffering from thromboembolic diseases as well as for patients with atrial fibrillation: Because of constant bioavailability, fixed dose regimen treatment is possible, monitoring not necessary and severe bleeding complications-particularly intracranial hemorrhages-rare in comparison to vitamin K anticoagulants. To gain all these advantages, it is essential to give DOAC in the correct dosage. Dose reduction of single DOAC has to be considered depending on underlying disease, body weight and renal function. DOAC are not allowed in patients with artificial heart valves, in pregnancy and in children. In case of severe bleeding complications under DOAC treatment, prothrombin complex concentrates is one treatment option. For dabigatran an antidote is available.

Management of patients with high-risk pulmonary embolism: a narrative review

High-risk pulmonary embolism (PE) is a life-threatening disorder associated with high mortality and morbidity. Most deaths in patients with shock occur within the first few hours after presentation, and rapid diagnosis and treatment is therefore essential to save patients’ lives. The main manifestations of major PE are acute right ventricular (RV) failure and hypoxia. RV pressure overload is predominantly related to the interaction between the mechanical pulmonary vascular obstruction and the underlying cardiopulmonary status. Computed tomography angiography allows not only adequate visualization of the pulmonary thromboemboli down to at least the segmental level but also RV enlargement as an indicator of RV dysfunction. Bedside echocardiography is an acceptable alternative under such circumstances. Although it does not usually provide a definitive diagnosis or exclude pulmonary embolism, echocardiography can confirm or exclude severe RV pressure overload and dysfunction. Extracorporeal membrane oxygenation support can be an effective procedure in patients with PE-induced circulatory collapse. Thrombolysis is generally accepted in unstable patients with high-risk PE; however, thrombolytic agents cannot be fully administered to patients with a high risk of bleeding. Conversely, catheter-directed treatment is an optimal treatment strategy for patients with high-risk PE who have contraindications for thrombolysis and is a minimally invasive alternative to surgical embolectomy. It can be performed with a minimum dose of thrombolytic agents or without, and it can be combined with various procedures including catheter fragmentation or embolectomy in accordance with the extent of the thrombus on a pulmonary angiogram. Hybrid catheter-directed treatment can reduce a rapid heart rate and high pulmonary artery pressure and can improve the gas exchange indices and outcomes. Surgical embolectomy is also performed in patients with contraindications for or an inadequate response to thrombolysis. Large hospitals having an intensive care unit should preemptively establish diagnostic and therapeutic protocols and rehearse multidisciplinary management for patients with high-risk PE. Coordination with a skilled team comprising intensivists, cardiologists, cardiac surgeons, radiologists, and other specialists is crucial to maximize success.

De l’entrée à la sortie du service de réanimation adulte : une mise au point sur l’utilisation courante du monitoring du CO2 expiré

L’objectif de cette mise au point est d’effectuer une revue des indications de l’utilisation du monitorage du CO2 expiré en réanimation adulte. De par sa physiologie, sa mesure est un reflet de l’état hémodynamique, respiratoire et métabolique du patient. La spectrométrie infrarouge est la méthode de mesure la plus courante. La capnographie commune (CO2 expiré en fonction du temps) est divisée en plusieurs phases dont l’analyse visuelle peut faire évoquer de nombreuses anomalies ventilatoires. La capnographie volumétrique fournit une mesure de l’espace mort. La capnométrie est recommandée en réanimation pour contrôler l’intubation trachéale ou bien au cours d’un arrêt cardiorespiratoire comme facteur pronostique. Tout patient traité par ventilation mécanique invasive, surtout lors d’un transport, doit être équipé d’un capnomètre afin d’anticiper toute complication respiratoire (extubation, bronchospasme, hypoventilation). La pression de fin d’expiration en CO2 (PetCO2) est une évaluation de la pression artérielle en CO2 (PaCO2) utile pour limiter le nombre de prélèvements biologiques, par exemple en neuroréanimation, mais de nombreux facteurs font varier le gradient entre ces deux valeurs. Les études n’apportent pas de preuve pour l’utilisation de la capnographie volumétrique dans le diagnostic d’embolie pulmonaire en réanimation. Chez les patients souffrant de syndrome de détresse respiratoire aiguë, la littérature médicale n’apporte pas de preuve suffisante pour un intérêt en pratique clinique courante de la capnométrie volumétrique qui semble limitée dans ce cas à la recherche.

Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism

BACKGROUND

In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models.

METHODS

We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE.

RESULTS

According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%-7.0%), compared with those without DVT (0.6%; 95% CI, 0%-3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0).

CONCLUSIONS

In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.

The diagnosis and treatment of venous thromboembolism in asian patients

Although the incidence of venous thromboembolism (VTE) in Asian populations is lower than in Western countries, the overall burden of VTE in Asia has been considerably underestimated. Factors that may explain the lower prevalence of VTE in Asian populations relative to Western populations include the limited availability of epidemiological data in Asia, ethnic differences in the genetic predisposition to VTE, underdiagnoses, low awareness toward thrombotic disease, and possibly less symptomatic VTE in Asian patients. The clinical assessment, diagnostic testing, and therapeutic considerations for VTE are, in general, the same in Asian populations as they are in Western populations. The management of VTE is based upon balancing the treatment benefits against the risk of bleeding. This is an especially important consideration for Asian populations because of increased risk of intracranial hemorrhage with vitamin K antagonists. Non-vitamin K antagonist oral anticoagulants have shown advantages over current treatment modalities with respect to bleeding outcomes in major phase 3 clinical trials, including in Asian populations. Although anticoagulant therapy has been shown to reduce the risk of postoperative VTE in Western populations, VTE prophylaxis is not administered routinely in Asian countries. Despite advances in the management of VTE, data in Asian populations on the incidence, prevalence, recurrence, risk factors, and management of bleeding complications are limited and there is need for increased awareness. To that end, this review summarizes the available data on the epidemiology, risk stratification, diagnosis, and treatment considerations in the management of VTE in Asia.

Pulmonary embolism four days after interruption of therapy with rivaroxaban

Thrombosis after cessation of anticoagulation, also named rebound thrombosis, is a matter of concern and controversy. There are only few published data about occurrence of rebound thrombosis associated with non-vitamin K-antagonist oral anticoagulant drugs (NOACs). We report on a 58-year-old male with paroxysmal atrial fibrillation (AF) with a CHA2DS2VASC score of 4 who developed central pulmonary embolism four days after interruption of rivaroxaban because of parotid surgery. He had received 40 mg enoxaparin/d. The parotid gland was partially resected within 6 hours without blood loss. Pulmonary embolism and AF occurred on the first postoperative day. He recovered with low-molecular-weight heparin in therapeutic dosages and amiodarone and was discharged with phenprocoumon. The relevance of a rivaroxaban rebound phenomenon, manifesting as arterial embolism, stroke or venous thromboembolism should be clarified. It should be assessed if rebound-phenomena also exist for the NOACs dabigatran, apixaban and edoxaban. Thus, the randomized trials and registries investigating patients with AF or venous thromboembolism should be re-analysed and, based on these data, recommendations should be developed for situations in which NOAC-therapy has to be interrupted or ceased.

Endovenous Treatment for Acute Massive Pulmonary Thromboembolism

Treatment for venous thromboembolic conditions differs significantly depending on whether the condition is acute or chronic. Endovenous treatment is now available for treating the most severe cases of acute massive pulmonary thromboembolism, and the goal is rapid central clot removal to relieve life-threatening pulmonary circulation. Endovenous catheter interventions include catheter-directed thrombolysis and catheter-assisted thrombus removal. The latter is divided into aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. Data from cohort studies indicate that the clinical outcome and safety after open surgical treatment and endovenous treatment may be comparable. This paper reviews the current approaches to endovenous treatment for acute massive pulmonary thromboembolism, and presents our study of hybrid treatment using a combination of local fibrinolysis, mechanical fragmentation, and clot aspiration.

Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism

BACKGROUND AND OBJECTIVE

To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications.

PATIENTS AND METHODS

This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE.

RESULTS

Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049).

CONCLUSIONS

The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.

Exploring unmet needs in venous and arterial thromboembolism with rivaroxaban

The vast clinical research programme for the direct, oral factor Xa inhibitor rivaroxaban has generated a wealth of data since the first rivaroxaban approval in 2008 for the prevention of venous thrombo embolism (VTE) in patients undergoing elective hip or knee replacement surgery. While rivaroxaban is widely used across a spectrum of seven indications, there is continuous commitment to investigating its wider benefits in new indications and attempts to refine current evidence. Key data from recently completed randomised controlled trials (RCTs) have shown that rivaroxaban is a feasible anticoagulation option for patients with non-valvular atrial fibrillation (NVAF) undergoing cardioversion or catheter ablation. Now, a number of Phase II and III RCTs are underway that seek to uncover further roles for rivaroxaban in patients at risk of thrombosis and aim to improve quality of life. This article will introduce and provide context for these RCTs in the contemporary management of arterial and venous thromboembolism in the following underserved areas: Patients with both NVAF and acute coronary syndrome (ACS) requiring percutaneous coronary intervention (PCI); patients with embolic stroke of undetermined source (ESUS); patients who require transcatheter aortic valve replacement (TAVR); patients with acute or chronic coronary artery disease (CAD; including those with heart failure [HF]); those at risk of or suffering from cancer-associated thrombosis (CAT) and those requiring long-term anticoagulation. It is hoped that this collection of studies provides clarity around the use of rivaroxaban as a fundamental component of antithrombotic therapy in an array of clinical situations.