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Cimini LA, Luijten D, Barco S, Ghanima W, Jervan Ø, Kahn SR, Konstantinides S, Lachant D, Nakano Y, Ninaber M, van Es J, van Mens T, Vonk Noordegraaf A, Becattini C, Klok FA. Pulmonary perfusion defects or residual vascular obstruction and persistent symptoms after pulmonary embolism: a systematic review and meta-analysis. ERJ Open Res 2024; 10:01010-2023. [PMID: 39076522 PMCID: PMC11284598 DOI: 10.1183/23120541.01010-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/20/2024] [Indexed: 07/31/2024] Open
Abstract
Introduction Up to 50% of pulmonary embolism (PE) patients have perfusion defects or residual vascular obstruction during follow-up despite adequate anticoagulant treatment, and a similar percentage experience chronic functional limitations and/or dyspnoea post-PE. We aimed to evaluate the association between pulmonary perfusion defects or residual vascular obstruction and functional recovery after PE. Methods We performed a systematic review and meta-analysis including studies assessing both the presence of perfusion defects or residual vascular obstruction and functional recovery (i.e. persistent symptoms, quality of life, exercise endurance). An odds ratio was pooled for perfusion defects or residual vascular obstruction and persistent symptoms using a random-effect model. Results 12 studies were included totalling 1888 PE patients; at a median of 6 months after PE (range 2-72 months), 34% had perfusion defects or residual vascular obstruction and 37% reported persistent symptoms. Among patients with perfusion defects or residual vascular obstruction, 48% (95% CI 37-60%, I2=82%) remained symptomatic during follow-up, compared to 34% (95% CI 20-51%, I2=96%) of patients without such defects. Presence of perfusion defects or residual vascular obstruction was associated with persistent symptoms (OR 2.15, 95% CI 1.66-2.78; I2=0%, τ=0). Notably, there was no association between these defects and quality of life or cardiopulmonary exercise test parameters. Conclusion While the odds of having persistent symptoms was higher in patients with perfusion defects or residual vascular obstruction after acute PE, a significant proportion of these patients reported no limitations. A possible causality between perfusion defects or residual vascular obstruction and residual functional limitation therefore remains to be proven.
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Affiliation(s)
- Ludovica Anna Cimini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Dieuwke Luijten
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Øyvind Jervan
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Susan R. Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josien van Es
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Pulmonology, OLVG, Amsterdam, The Netherlands
| | - Thijs van Mens
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Becattini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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2
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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [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] [Received: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Xue L, Zhong Q, Xu N, Zheng Y, Liu Y. Investigation in image quality and immediate patient safety using pre-dual-flow injection for low-contrast dose spectral pulmonary artery CT angiography. Eur J Radiol Open 2024; 12:100571. [PMID: 38859979 PMCID: PMC11163167 DOI: 10.1016/j.ejro.2024.100571] [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: 03/13/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 06/12/2024] Open
Abstract
Purpose The patient safety of iodine contrast-enhanced pulmonary artery CT angiography (CTPA) is widely concerned. This study aimed to investigate the image quality and immediate patient safety of spectral CTPA using a lower-contrast dose pre-dual-flow injection method. Methods This retrospective study included 120 patients with suspected pulmonary embolisms who received spectral CTPA between February and December 2022. Patients were divided into normal contrast injection (Group A, n=60) and pre-dual-flow group (Group B, n=60). CT values of pulmonary arteries (PAs) at different levels, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), arteriovenous separation performance, and beam hardening artifact (BHA) index of two sets of images were measured or calculated. The subjective image quality and immediate patient safety were also scored using the three-point method. Results Group B had a contrast dose reduction by 42.5 % (60 vs. 34.5 mL). Radiation exposure dose was not statistically different between the two groups (P>0.05). CT values of different-level PAs on group B images were higher than those on group A images (P<0.05). Group B images had higher SNR and CNR, better arteriovenous separation between PA trunk and pulmonary vein, and lower BHA index on soft tissue and PA (all P<0.05). For subjective evaluation of image quality, group B had a better score in beam hardening artifact (P<0.05). For immediate patient safety, the score in comfortability was statistically higher in group B, with P<0.05. Conclusions Comparing with the normal injection method, pre-dual-flow spectral CTPA with a lower contrast dose injected results in better image quality and shows potential in patient-safety promotion.
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Affiliation(s)
- Liwei Xue
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qing Zhong
- Department of Gastric surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Nianjie Xu
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yanping Zheng
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yuanfen Liu
- Department of Imaging, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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Zieliński D, Darocha S, Pietrasik A, Machowski M, Wróbel K, Kurzyna M, Pruszczyk P, Torbicki A, Biederman A. Chronic thromboembolic disease among patients undergoing surgical pulmonary embolectomy for acute pulmonary embolism. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:302-310. [PMID: 38635283 DOI: 10.23736/s0021-9509.24.12931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND This study aimed to assess the prevalence of chronic thromboembolic lesions in the pulmonary arteries among patients undergoing pulmonary embolectomy for acute pulmonary embolism and their impact on treatment outcomes. METHODS We conducted a retrospective, single-center analysis of consecutive patients undergoing emergency pulmonary embolectomy for acute pulmonary embolism between 2013 and August 2021. According to European Society of Cardiology guidelines, the diagnosis was based on clinical presentation, imaging studies and laboratory tests. Surgery was selected as the optimal treatment modality within the Pulmonary Embolism Response Team. Based on the intraoperatively identified chronic lesions patients were divided into two groups: acute only and acute/chronic. The analysis comprised history, laboratory and imaging studies, early and long-term mortality, and postoperative complications. We determined predictive factors for chronic thromboembolic lesions and risk factors for death. RESULTS The analysis included 33 patients. Intraoperatively, 42% (14) of patients had chronic lesions. Predictive factors for these lesions are the duration of symptoms >1 week (OR=13.75), pulmonary artery dilatation >3.15 cm (OR=39.00) and right ventricle systolic pressure >52 mmHg (OR=29.33). No hospital deaths occurred in the acute only group and two in the acute/chronic group (0% vs. 14.3%; P=0.172). Risk factors for death are the duration of symptoms >3 weeks (HR=7.35) and postoperative use of extracorporeal membrane oxygenation (HR=7.04). CONCLUSIONS Acute thromboembolic disease overlapping chronic clots is relatively common among patients undergoing pulmonary artery embolectomy. A detailed evaluation of the patient's medical history and imaging studies can identify these patients, as they require special attention when making treatment decisions. Surgical treatment in a center of expertise in pulmonary endarterectomy seems reasonable.
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Affiliation(s)
- Dariusz Zieliński
- Department of Cardiac Surgery, Medicover Hospital, Warsaw, Poland -
- Faculty of Medicine, Lazarski University, Warsaw, Poland -
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, Otwock, Poland
- European Health Center, Otwock, Poland
| | | | - Michał Machowski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Wróbel
- Department of Cardiac Surgery, Medicover Hospital, Warsaw, Poland
- Faculty of Medicine, Lazarski University, Warsaw, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, Otwock, Poland
- European Health Center, Otwock, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, Otwock, Poland
- European Health Center, Otwock, Poland
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Meyer FJ, Opitz C. Post-Pulmonary Embolism Syndrome: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:128-134. [PMID: 38531395 DOI: 10.1055/a-2229-4190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
In survivors of acute pulmonary embolism (PE), the post-PE syndrome (PPES) may occur. In PPES, patients typically present with persisting or progressive dyspnea on exertion despite 3 months of therapeutic anticoagulation. Therefore, a structured follow-up is warranted to identify patients with chronic thromboembolic pulmonary disease (CTEPD) with normal pulmonary pressure or chronic thromboembolic pulmonary hypertension (CTEPH). Both are currently understood as a dual vasculopathy, that is, secondary arterio- and arteriolopathy, affecting the large and medium-sized pulmonary arteries as well as the peripheral vessels (diameter < 50 µm). The follow-up algorithm after acute PE commences with identification of clinical symptoms and risk factors for CTEPH. If indicated, a stepwise performance of echocardiography, ventilation-perfusion scan (or alternative imaging), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, cardiopulmonary exercise testing, and pulmonary artery catheterization with angiography should follow. CTEPH patients should be treated in a multidisciplinary center with adequate experience in the complex therapeutic options, comprising pulmonary endarterectomy, balloon pulmonary angioplasty, and pharmacological interventions.
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Affiliation(s)
- F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching) - München Klinik gGmbH, Sanatoriumsplatz 2 München, München, Bavaria, Germany
| | - Christian Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK Kliniken Berlin Westend, Berlin, Germany
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6
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Howard LS, Price LC. Systematic pulmonary embolism follow-up: why we should all do it! Eur Respir J 2024; 63:2400253. [PMID: 38485183 DOI: 10.1183/13993003.00253-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Luke S Howard
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, Guys and Thomas's NHS Foundation Trust, London, UK
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Hrdlicka J, Jurka M, Bircakova B, Ambroz D, Jansa P, Burgetova A, Lambert L. Even non-expert radiologists report chronic thromboembolic pulmonary hypertension (CTEPH) on CT pulmonary angiography with high sensitivity and almost perfect agreement. Eur Radiol 2024; 34:1086-1093. [PMID: 37606660 DOI: 10.1007/s00330-023-10098-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/15/2023] [Accepted: 06/25/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVES To assess the diagnostic performance and interobserver agreement of CT pulmonary angiography (CTPA) in the detection of chronic thromboembolic pulmonary hypertension (CTEPH) and its features among radiologists of different levels of experience. MATERIALS AND METHODS In this retrospective, single-center, single-blinded study, three radiologists with different levels of experience in CT imaging (R1:15 years, R2:6 years, and R3:3 years) evaluated CTPA of 51 patients ultimately diagnosed with CTEPH (European Society of Cardiology guidelines) and 49 patients without CTEPH in random order to assess the presence of CTEPH, its features in the pulmonary artery tree, proximal level of involvement, bronchial artery hypertrophy, mosaic perfusion, and right heart overload. RESULTS CTPAs of 51 patients with CTEPH (median age, 66 years (IQR 56-72), 28 men) and 49 patients without CTEPH (median age, 65 years (IQR 50-74), 25 men) were evaluated. The sensitivity and specificity for the detection of CTEPH was 100% (all radiologists) and 100% (R1), 96% (R2), and 96% (R3) with almost perfect agreement (κ = 0.95). The sensitivity and specificity for detecting CTEPH by mosaic perfusion would be 89% (95%CI 83-93%) and 81% (74-87%). The level of pulmonary artery involvement was reported with moderate agreement (κ = 0.54, 95%CI 0.40-0.65). Substantial agreement was found in the evaluation of mosaic attenuation (κ = 0.75, 95%CI 0.64-0.84), right heart overload (κ = 0.68, 95%CI 0.56-0.79), and bronchial artery hypertrophy (0.71, 95%CI 0.59-0.82) which were the best predictors of CTEPH (p < 0.0001). CONCLUSIONS CTPA has high sensitivity and specificity in detecting CTEPH and almost perfect agreement among radiologists of different levels of expertise. CLINICAL RELEVANCE CT pulmonary angiography can be used as a first-line imaging modality in patients with suspected chronic thromboembolic pulmonary hypertension (CTEPH) even when interpreted by non-CTEPH experts. KEY POINTS • CT pulmonary angiography has high sensitivity and specificity in detecting chronic thromboembolic pulmonary hypertension (CTEPH) and almost perfect interobserver agreement among radiologists of different levels of expertise. • Substantial agreement exists in the assessment of mosaic attenuation, right heart overload, and bronchial artery hypertrophy, which are the best predictors of CTEPH.
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Affiliation(s)
- Jan Hrdlicka
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Martin Jurka
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Bianka Bircakova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - David Ambroz
- 2nd Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Pavel Jansa
- 2nd Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Andrea Burgetova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Lukas Lambert
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
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Lai Y, Chen M, Chen M, Li C, Chen X, Lai Y, Zheng Z, Chen R. Gender differences in the incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: A meta-analysis. Medicine (Baltimore) 2024; 103:e35150. [PMID: 38241593 PMCID: PMC10798717 DOI: 10.1097/md.0000000000035150] [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: 02/28/2023] [Accepted: 08/18/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND To explore the role of gender in the incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. METHODS Two researchers search the PubMed Database, Embase Database and Cochrane Library Database from their establishment to October 2022, using Endnote software for document management and RevMan5.3 software for the meta-analysis of the included literature. A total of 11 studies are selected, including 5788 acute pulmonary embolism events and 391 patients (179 males and 212 females) with chronic thromboembolic pulmonary hypertension (CTEPH) under the stated conditions. The results show that there is no statistically significant difference in the incidence of CTEPH between males and females after PE (P = .28), with combined OR of 0.89 and 95% CI 0.72-1.10. RESULTS AND CONCLUSIONS Gender is found to be absent as a factor in the incidence of CTEPH after acute pulmonary embolism. This may indicate that gender is not a risk factor for CTEPH and that female patients are not necessarily more likely to have a higher incidence than male patients. As such, accurate judgments should be made on the possible complications of all patients after acute pulmonary embolism, which will be conducive to early detection and intervention in the treatment of CTEPH.
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Affiliation(s)
- Yuanqiang Lai
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- China State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Clinical Medicine, The First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Minshan Chen
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- China State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Clinical Medicine, The First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Mingdi Chen
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Chunhe Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaojuan Chen
- Medical College of Jiaying University, Meizhou, China
| | - Yuanzhi Lai
- Department of Clinical Medicine, The First Clinical School of Southern Medical University, Guangzhou, China
| | - Zhenzhen Zheng
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Riken Chen
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
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Marin-Romero S, Ballaz-Quincoces A, Gómez-Cuervo C, Marchena-Yglesias PJ, Lopez-Miguel P, Francisco-Albesa I, Pedrajas-Navas JM, Lumbierres M, Aibar-Arregui MA, Bosco Lopez-Saez J, Perez-Pinar M, Baeza-Martinez C, Riera-Mestre A, Peris-Sifre M, Porras-Ledantes JA, Criado-Garcia J, Elias-Hernandez T, Otero R, Barca-Hernando M, Muriel A, Klok FA, Jara-Palomares L. Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study. Thorax 2024; 79:144-152. [PMID: 38050187 PMCID: PMC10850838 DOI: 10.1136/thorax-2023-220580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/16/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors. METHODS This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC. RESULTS Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed. CONCLUSIONS The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier. TRIAL REGISTRATION NUMBER NCT03953560.
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Affiliation(s)
- Samira Marin-Romero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | | | | | | | | | | | - Marina Lumbierres
- Respiratory Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | | | | | | | | | - Antoni Riera-Mestre
- Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
- Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
- Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain
| | - Marisa Peris-Sifre
- Internal Medicine Unit, Hospital Provincial Castellon, Castellon de la Plana, Spain
- CEU Cardenal Herrera University, Moncada, Spain
| | | | | | - Teresa Elias-Hernandez
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Remedios Otero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Maria Barca-Hernando
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Alfonso Muriel
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
- Biostatistics Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
- University of Alcala, Alcala de Henares, Spain
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Luis Jara-Palomares
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
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10
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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11
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Adameit MSD, Wiedenroth CB, Omlor A, Schäfers HJ, Guth S, Wilkens H. [Chronic thromboembolic pulmonary hypertension]. Dtsch Med Wochenschr 2023; 148:1514-1523. [PMID: 37949080 DOI: 10.1055/a-2012-0899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease, but an important late sequela after acute pulmonary embolism. Therefore, follow-up after at least three months of sufficient anticoagulation is recommended. Patients with suspected CTEPH should be referred to specialized CTEPH centers for further evaluation and treatment.Three treatment modalities are available: pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and pulmonary hypertension-targeted drugs. The indication for surgery depends mainly on the localization of the pulmonary arterial obstructions. Severe comorbidities as well as advanced age need individual evaluation, but do not present strict exclusion criteria. Multimodal treatments are common practice in inoperable CTEPH. However, treatment decision making in an experienced multidisciplinary team is mandatory.
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12
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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13
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Konstantinides S. Modern Lung Scintigraphy Techniques for Optimizing the Diagnosis of Pulmonary Embolism: Great Expectations Still Awaiting to Be Met. Thromb Haemost 2023; 123:663-665. [PMID: 36934721 DOI: 10.1055/a-2057-8672] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Affiliation(s)
- Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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14
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Luijten D, Talerico R, Barco S, Cannegieter SC, Delcroix M, Ende-Verhaar YM, Huisman MV, Konstantinidis S, Mairuhu ATA, van Mens TE, Ninaber M, Pruszczyk P, Vonk Noordegraaf A, Klok FA. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: an updated systematic review and meta-analysis. Eur Respir J 2023; 62:2300449. [PMID: 37321620 DOI: 10.1183/13993003.00449-2023] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Talerico
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Suzanne C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marion Delcroix
- Department of Respiratory Diseases, University Hospital of Leuven, Leuven, Belgium
| | - Yvonne M Ende-Verhaar
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Albert T A Mairuhu
- Department of Vascular Medicine, Haga Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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15
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Gleditsch J, Jervan Ø, Klok F, Holst R, Hopp E, Tavoly M, Ghanima W. Does the clot burden as assessed by the Mean Bilateral Proximal Extension of the Clot score reflect mortality and adverse outcome after pulmonary embolism? Acta Radiol Open 2023; 12:20584601231187094. [PMID: 37426515 PMCID: PMC10328056 DOI: 10.1177/20584601231187094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/24/2023] [Indexed: 07/11/2023] Open
Abstract
Background Rapid diagnosis and risk stratification are important to reduce the risk of adverse clinical events and mortality in acute pulmonary embolism (PE). Although clot burden has not been consistently shown to correlate with disease outcomes, proximally located PE is generally perceived as more severe. Purpose To explore the ability of the Mean Bilateral Proximal Extension of the Clot (MBPEC) score to predict mortality and adverse outcome. Methods This was a single center retrospective cohort study. 1743 patients with computed tomography pulmonary arteriography (CTPA) verified PE diagnosed between 2005 and 2020 were included. Patients with active malignancy were excluded. The PE clot burden was assessed with MBPEC score: The most proximal extension of PE was scored in each lung from 1 = sub-segmental to 4 = central. The MBPEC score is the score from each lung divided by two and rounded up to nearest integer. Results We found inconsistent associations between higher and lower MBPEC scores versus mortality. The all-cause 30-day mortality of 3.9% (95% CI: 3.0-4.9). The PE-related mortality was 2.4% (95% CI: 1.7-3.3). Patients with MBPEC score 1 had higher all-cause mortality compared to patients with MBPEC score 4: Crude Hazard Ratio (cHR) was 2.02 (95% CI: 1.09-3.72). PE-related mortality was lower in patients with MBPEC score 3 compared to score 4: cHR 0.22 (95% CI: 0.05-0.93). Patients with MBPEC score 4 did more often receive systemic thrombolysis compared to patients with MBPEC score 1-3: 3.2% vs. 0.6% (p < .001). Patients with MBPEC score 4 where more often admitted to the intensive care unit: 13% vs. 4.7% (p < .001). Conclusion We found no consistent association between the MBPEC score and mortality. Our results therefore indicate that peripheral PE does not necessarily entail a lower morality risk than proximal PE.
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Affiliation(s)
- Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
| | - Øyvind Jervan
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
- Department of Cardiology, Østfold Hospital, Kalnes, Norway
| | - Frederikus Klok
- Department of Medicine – Thrombosis
and Hemostasis, Leiden University Medical
Center, Leiden, The Netherlands
| | - René Holst
- Oslo Centre for Biostatistics and
Epidemiology, University of Oslo and Oslo
University Hospital, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear
Medicine, Oslo University
Hospital, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University
Hospital, Gothenburg, Sweden
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway
- Department of Hematology, Oslo
University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Zhai Z, Boon GJAM, Staring M, van Dam LF, Kroft LJM, Hernández Girón I, Ninaber MK, Bogaard HJ, Meijboom LJ, Vonk Noordegraaf A, Huisman MV, Klok FA, Stoel BC. Automated quantification of the pulmonary vasculature in pulmonary embolism and chronic thromboembolic pulmonary hypertension. Pulm Circ 2023; 13:e12223. [PMID: 37128354 PMCID: PMC10148047 DOI: 10.1002/pul2.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
The shape and distribution of vascular lesions in pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH) are different. We investigated whether automated quantification of pulmonary vascular morphology and densitometry in arteries and veins imaged by computed tomographic pulmonary angiography (CTPA) could distinguish PE from CTEPH. We analyzed CTPA images from a cohort of 16 PE patients, 6 CTEPH patients, and 15 controls. Pulmonary vessels were extracted with a graph-cut method, and separated into arteries and veins using deep-learning classification. Vascular morphology was quantified by the slope (α) and intercept (β) of the vessel radii distribution. To quantify lung perfusion defects, the median pulmonary vascular density was calculated. By combining these measurements with densities measured in parenchymal areas, pulmonary trunk, and descending aorta, a static perfusion curve was constructed. All separate quantifications were compared between the three groups. No vascular morphology differences were detected in contrast to vascular density values. The median vascular density (interquartile range) was -567 (113), -452 (95), and -470 (323) HU, for the control, PE, and CTEPH group. The static perfusion curves showed different patterns between groups, with a statistically significant difference in aorta-pulmonary trunk gradient between the PE and CTEPH groups (p = 0.008). In this proof of concept study, not vasculature morphology but densities differentiated between patients of three groups. Further technical improvements are needed to allow for accurate differentiation between PE and CTEPH, which in this study was only possible statistically by measuring the density gradient between aorta and pulmonary trunk.
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Affiliation(s)
- Zhiwei Zhai
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gudula J. A. M. Boon
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Marius Staring
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Lisette F. van Dam
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Irene Hernández Girón
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Maarten K. Ninaber
- Department of PulmonologyLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Menno V. Huisman
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Berend C. Stoel
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
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17
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Held M, Pfeuffer-Jovic E, Wilkens H, Güder G, Küsters F, Schäfers HJ, Langen HJ, Cheufou D, Schmitt D. Frequency and characterization of CTEPH and CTEPD according to the mPAP threshold > 20 mm Hg: Retrospective analysis from data of a prospective PE aftercare program. Respir Med 2023; 210:107177. [PMID: 36868431 DOI: 10.1016/j.rmed.2023.107177] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND The influence of the new pulmonary hypertension (PH) definition on the incidence of chronic thromboembolic PH (CTEPH) is unclear. The incidence of chronic thromboembolic pulmonary disease without PH (CTEPD) is unknown. OBJECTIVES To determine the frequency of CTEPH and CTEPD using the new mPAP cut-off >20 mmHg for PH in patients who have suffered an incidence of pulmonary embolism (PE) and were recruited into an aftercare program. METHODS In a prospective two-year observational study based on telephone calls, echocardiography and cardiopulmonary exercise tests, patients with findings suspicious for PH received an invasive work-up. Data from right heart catheterization were used to identify patients with or without CTEPH/CTEPD. RESULTS Two years after acute PE (n = 400) we found an incidence of 5.25% for CTEPH (n = 21) and 5.75% for CTEPD (n = 23) according to the new mPAP threshold >20 mmHg. Five of 21 patients with CTEPH and 13 of 23 patients with CTEPD showed no signs of PH in echocardiography. CTEPH and CTEPD subjects showed a reduced VO₂ peak and work rate in cardiopulmonary exercise testing (CPET). The capillary end-tidal CO2 gradient was comparably elevated in CTEPH and CTEPD, but it was normal in the Non-CTEPD-Non-PH group. According to the PH definition provided by the former guidelines, only 17 (4.25%) patients have been diagnosed with CTEPH and 27 individuals (6.75%) were classified having CTEPD. CONCLUSIONS Using mPAP >20 mmHg for diagnosis of CTEPH leads to an increase of 23.5% of CTEPH diagnosis. CPET may help to detect CTEPD and CTEPH.
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Affiliation(s)
- Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany.
| | - Elena Pfeuffer-Jovic
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany
| | - Heinrike Wilkens
- Department of Respiratory Medicine, Allergology, Intensive Care and Environmental Medicine, University Hospital of Saarland, Homburg Saar, Germany
| | - Gülmisal Güder
- Department of Internal Medicine I, University Hospital, Julius Maximilian University, German Heart Failure Center, Würzburg, Germany
| | - Franziska Küsters
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany
| | - Hans Joachim Schäfers
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Saarland, Homburg Saar, Germany
| | - Heinz Jakob Langen
- Department of Radiology, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany
| | - Danjouma Cheufou
- Department of Thoracic Surgery, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany
| | - Delia Schmitt
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital Klinikum Würzburg Mitte, Academic Teaching Hospital of the Julius Maximilian University, Würzburg, Germany
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18
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Luijten D, Klok FA, van Mens TE, Huisman MV. Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research. Expert Rev Respir Med 2023; 17:181-189. [PMID: 36912598 DOI: 10.1080/17476348.2023.2190888] [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] [Received: 12/19/2022] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. AREAS COVERED (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. EXPERT OPINION Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
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19
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Barco S, Mavromanoli AC, Kreitner KF, Bunck AC, Gertz RJ, Ley S, Valerio L, Klok FA, Gerhardt F, Rosenkranz S, Konstantinides SV. Preexisting Chronic Thromboembolic Pulmonary Hypertension in Acute Pulmonary Embolism. Chest 2023; 163:923-932. [PMID: 36621756 DOI: 10.1016/j.chest.2022.11.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. RESEARCH QUESTION Which radiologic findings on CT pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of preexisting CTEPH? STUDY DESIGN AND METHODS This study included unselected patients with acute PE who were prospectively followed up for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for preexisting CTEPH; in case of disagreement, a decision was reached by a 2:1 majority with a third expert radiologist. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. RESULTS Signs of chronic PE or CTEPH at baseline were identified in 46 of 303 included patients (15%). Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days following acute PE) were found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of preexisting CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. INTERPRETATION Searching for predefined radiologic parameters suggesting preexisting CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karl-Friedrich Kreitner
- Department of Radiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Alexander C Bunck
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Roman J Gertz
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sebastian Ley
- Diagnostic and Interventional Radiology, Artemed Klinikum München Süd, Munich, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology I, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix Gerhardt
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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20
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Luijten D, Meijer FMM, Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Huisman MV, Mairuhu ATA, Middeldorp S, Pruszcyk P, Ruigrok D, Verhamme P, Vonk Noordegraaf A, Vriend JWJ, Vliegen HW, Klok FA. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol 2022; 74:94-100. [PMID: 36057190 DOI: 10.1016/j.jelectrocard.2022.08.007] [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: 06/03/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Application of the chronic thromboembolic pulmonary hypertension (CTEPH) rule out criteria (manual electrocardiogram [ECG] reading and N-terminal pro-brain natriuretic peptide [NTproBNP] test) can rule out CTEPH in pulmonary embolism (PE) patients with persistent dyspnea (InShape II algorithm). Increased pulmonary pressure may also be identified using automated ECG-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHOD A predefined analysis of the InShape II study was performed. The diagnostic performance of the VG-RVPO for the detection of CTEPH and the incremental diagnostic value of the VG-RVPO as new rule-out criteria in the InShape II algorithm were evaluated. RESULTS 60 patients were included; 5 (8.3%) were ultimately diagnosed with CTEPH. The mean baseline VG-RVPO (at time of PE diagnosis) was -18.12 mV·ms for CTEPH patients and - 21.57 mV·ms for non-CTEPH patients (mean difference 3.46 mV·ms [95%CI -29.03 to 35.94]). The VG-RVPO (after 3-6 months follow-up) normalized in patients with and without CTEPH, without a clear between-group difference (mean Δ VG-RVPO of -8.68 and - 8.42 mV·ms respectively; mean difference of -0.25 mV·ms, [95%CI -12.94 to 12.44]). The overall predictive accuracy of baseline VG-RVPO, follow-up RVPO and Δ VG-RVPO for CTEPH was moderate to poor (ROC AUC 0.611, 0.514 and 0.539, respectively). Up to 76% of the required echocardiograms could have been avoided with VG-RVPO criteria replacing the InShape II rule-out criteria, however at cost of missing up to 80% of the CTEPH diagnoses. CONCLUSION We could not demonstrate (additional) diagnostic value of VG-RVPO as standalone test or as on top of the InShape II algorithm.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur M M Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Piotr Pruszcyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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21
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Overton PM, Toshner M, Mulligan C, Vora P, Nikkho S, Jan de Backer, Lavon BR, Klok FA. Pulmonary thromboembolic events in COVID‐19 – a systematic literature review. Pulm Circ 2022; 12:e12113. [PMID: 35942076 PMCID: PMC9349961 DOI: 10.1002/pul2.12113] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/28/2022] [Accepted: 07/10/2022] [Indexed: 11/15/2022] Open
Abstract
Pulmonary thromboembolic events have been linked to coronavirus disease 2019 (COVID‐19), but their incidence and long‐term sequelae remain unclear. We performed a systematic literature review to investigate the incidence of pulmonary embolism (PE), microthrombi, thrombosis in situ (thromboinflammatory disease), and chronic thromboembolic pulmonary hypertension (CTEPH) during and after COVID‐19. PubMed and the World Health Organization Global Research Database were searched on May 7, 2021. Hospital cohort and database studies reporting data for ≥1000 patients and autopsy studies reporting data for ≥20 patients were included. Results were summarized descriptively. We screened 1438 records and included 41 references (32 hospital/database studies and 9 autopsy studies). The hospital/database studies reported the incidence of PE but not CTEPH, microthrombi, or thromboinflammatory disease. PE incidence varied widely (0%–1.1% of outpatients, 0.9%–8.2% of hospitalized patients, and 1.8%–18.9% of patients in intensive care). One study reported PE events occurring within 45 days after hospital discharge (incidence in discharged patients: 0.2%). Segmental arteries were generally the most common location for PE. In autopsy studies, PE, thromboinflammatory disease, and microthrombi were reported in 6%–23%, 43%–100%, and 45%–84% of deceased patients, respectively. Overall, the included studies mostly focused on PE during the acute phase of COVID‐19. The results demonstrate the challenges of identifying and characterizing vascular abnormalities using current protocols (e.g., visual computed tomography reads). Further research is needed to detect subtle pulmonary vascular abnormalities, distinguish thromboinflammatory disease from PE, optimize treatment, and assess the incidence of long‐term sequelae after COVID‐19.
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Affiliation(s)
| | - Mark Toshner
- Department of Medicine, School of Clinical Medicine University of Cambridge UK
| | | | | | | | | | | | - Frederikus A. Klok
- Department of Medicine–Thrombosis and Hemostasis Leiden University Medical Center Leiden the Netherlands
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