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Jorg T, Halfmann MC, Graafen D, Hobohm L, Düber C, Mildenberger P, Müller L. Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms. ROFO-FORTSCHR RONTG 2024. [PMID: 38806150 DOI: 10.1055/a-2301-3349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Structured reporting (SR) not only offers advantages regarding report quality but, as an IT-based method, also the opportunity to aggregate and analyze large, highly structured datasets (data mining). In this study, a data mining algorithm was used to calculate epidemiological data and in-hospital prevalence statistics of pulmonary embolism (PE) by analyzing structured CT reports.All structured reports for PE CT scans from the last 5 years (n = 2790) were extracted from the SR database and analyzed. The prevalence of PE was calculated for the entire cohort and stratified by referral type and clinical referrer. Distributions of the manifestation of PEs (central, lobar, segmental, subsegmental, as well as left-sided, right-sided, bilateral) were calculated, and the occurrence of right heart strain was correlated with the manifestation.The prevalence of PE in the entire cohort was 24% (n = 678). The median age of PE patients was 71 years (IQR 58-80), and the sex distribution was 1.2/1 (M/F). Outpatients showed a lower prevalence of 23% compared to patients from regular wards (27%) and intensive care units (30%). Surgically referred patients had a higher prevalence than patients from internal medicine (34% vs. 22%). Patients with central and bilateral PEs had a significantly higher occurrence of right heart strain compared to patients with peripheral and unilateral embolisms.Data mining of structured reports is a simple method for obtaining prevalence statistics, epidemiological data, and the distribution of disease characteristics, as demonstrated by the PE use case. The generated data can be helpful for multiple purposes, such as for internal clinical quality assurance and scientific analyses. To benefit from this, consistent use of SR is required and is therefore recommended. · SR-based data mining allows simple epidemiologic analyses for PE.. · The prevalence of PE differs between outpatients and inpatients.. · Central and bilateral PEs have an increased risk of right heart strain.. · Jorg T, Halfmann MC, Graafen D et al. Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2301-3349.
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Affiliation(s)
- Tobias Jorg
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Moritz C Halfmann
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dirk Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Hobohm
- Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Peter Mildenberger
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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2
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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3
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Silva D, Muders T, Wodack K, Putensen C, Leonhardt S, Siepmann R, Hentze B, Reinartz S. Pulmonary CT perfusion robustly measures cardiac output in the context of multilevel pulmonary occlusion: a porcine study. Eur Radiol Exp 2024; 8:51. [PMID: 38517595 PMCID: PMC10959917 DOI: 10.1186/s41747-024-00431-7] [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: 06/22/2023] [Accepted: 01/09/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND To validate pulmonary computed tomography (CT) perfusion in a porcine model by invasive monitoring of cardiac output (CO) using thermodilution method. METHODS Animals were studied at a single center, using a Swan-Ganz catheter for invasive CO monitoring as a reference. Fifteen pigs were included. Contrast-enhanced CT perfusion of the descending aorta and right and left pulmonary artery was performed. For variation purposes, a balloon catheter was inserted to block the contralateral pulmonary vascular bed; additionally, two increased CO settings were created by intravenous administration of catecholamines. Finally, stepwise capillary occlusion was performed by intrapulmonary arterial injection of 75-μm microspheres in four stages. A semiautomatic selection of AFs and a recirculation-aware tracer-kinetics model to extract the first-pass of AFs, estimating blood flow with the Stewart-Hamilton method, was implemented. Linear mixed models (LMM) were developed to calibrate blood flow calculations accounting with individual- and cohort-level effects. RESULTS Nine of 15 pigs had complete datasets. Strong correlations were observed between calibrated pulmonary (0.73, 95% confidence interval [CI] 0.6-0.82) and aortic blood flow measurements (0.82, 95% CI, 0.73-0.88) and the reference as well as agreements (± 2.24 L/min and ± 1.86 L/min, respectively) comparable to the state of the art, on a relatively wide range of right ventricle-CO measurements. CONCLUSIONS CT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by referencing the invasive CO. RELEVANCE STATEMENT Possible clinical applications of CT perfusion for measuring CO could be in acute pulmonary thromboembolism or to assess right ventricular function to show impairment or mismatch to the left ventricle. KEY POINTS • CT perfusion measures flow in vessels. • CT perfusion measures cumulative cardiac output in the aorta and pulmonary vessels. • CT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by using the invasive CO as a reference standard.
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Affiliation(s)
- Diogo Silva
- Medical Information Technology (MedIT), RWTH Aachen University, Aachen, Germany
| | - Thomas Muders
- Department of Anaesthesiology and Intensive Care Medicine, University Bonn, Bonn, Germany
| | - Karin Wodack
- Department of Anaesthesiology and Intensive Care Medicine, University Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Bonn, Bonn, Germany
| | - Steffen Leonhardt
- Medical Information Technology (MedIT), RWTH Aachen University, Aachen, Germany
| | - Robert Siepmann
- Department of Diagnostic and Interventional Radiology, Uniklinik RWTH Aachen, Aachen, Germany
| | - Benjamin Hentze
- Medical Information Technology (MedIT), RWTH Aachen University, Aachen, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Bonn, Bonn, Germany
| | - Sebastian Reinartz
- Department of Diagnostic and Interventional Radiology, Uniklinik RWTH Aachen, Aachen, Germany.
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4
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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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5
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Luijten D, Klok FA, van Mens TE, Huisman MV. Response to letter to the editor: "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; 17:427-428. [PMID: 37191014 DOI: 10.1080/17476348.2023.2215015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Dieuwke Luijten
- 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
| | - Thijs E van Mens
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Mu G, Li F, Chen X, Zhao B, Li G, Fu H. A visualized pulmonary arterial thrombus by using a modified echocardiographic view in an intermediate-risk acute pulmonary embolism patient: A case report. Clin Case Rep 2022; 10:e6105. [PMID: 35865766 PMCID: PMC9295681 DOI: 10.1002/ccr3.6105] [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: 03/07/2022] [Revised: 05/23/2022] [Accepted: 07/02/2022] [Indexed: 11/09/2022] Open
Abstract
Acute pulmonary embolism (APE) is a life‐threatening disease with nonspecific clinical signs and symptoms. Rapid and accurate diagnosis is crucial for the clinical management of patients with acute pulmonary embolism. A recommended echocardiography view may be of further help in the diagnosis and evaluation of the change in thrombosis and treatment. We reported a case of a 74‐year‐old man with a 12‐day history of decreased exercise capacity and dyspnea. The patient was diagnosed with intermediate‐risk APE as several pulmonary emboli in pulmonary artery were seen in multidetector computed tomographic pulmonary angiography with normal blood pressure and echocardiographic right ventricular overload. And we found a pulmonary artery clot in the right pulmonary artery through transthoracic echocardiography. After 11‐days anticoagulation, the patient underwent a reassessment, showed a decrease in RV diameter and pulmonary artery thrombus. This case highlights the significant role that echocardiography played in a patient who presented pulmonary embolism with a stable hemodynamic situation and normal blood pressure. The modified echocardiographic view could provide correct diagnosis by identifying the clot size and location visually. Knowledge of the echocardiography results of APE would aid the diagnosis.
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Affiliation(s)
- Guanyu Mu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Feixue Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Xiaolin Chen
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Bo Zhao
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Huaying Fu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
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7
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Quantitative volumetric computed tomography embolic analysis, the Qanadli score, biomarkers, and clinical prognosis in patients with acute pulmonary embolism. Sci Rep 2022; 12:7620. [PMID: 35538102 PMCID: PMC9090848 DOI: 10.1038/s41598-022-11812-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 04/18/2022] [Indexed: 11/09/2022] Open
Abstract
Detailed descriptions of acute pulmonary emboli (PE) morphology, total embolic volume (TEV), and their effects upon patients’ clinical presentation and prognosis remain largely unexplored. We studied 201 subjects with acute PE to the emergency department of a single medical center from April 2009 to December 2014. Patient hemodynamics, Troponin I and D-dimer levels, echocardiography, and the 30-day, 90-day and long-term mortality were obtained. Contrast-enhanced computed tomography (CT) of pulmonary structures and 3-dimensional measures of embolic burden were performed. The results showed a linear association between the greater TEV and each of the following 4 variables (increasing incidence of right ventricular (RV) dysfunction, higher systolic pulmonary artery pressure (sPAP), greater RV diameter, and RV/left ventricular (LV) ratio (all p < 0.001)). Among the measures of CT and echocardiography, TEV and RV/LV ratio were significantly associated with impending shock. In backward stepwise logistic regression, TEV, age and respiratory rate remained independent associated with impending shock (OR: 1.58, 1.03, 1.18, respectively and all p < 0.005).Total embolic burden assessed by CT-based quantification serves as a useful index for stressed cardiopulmonary circulation condition and can provide insights into RV dysfunction and the prediction of impending shock.
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8
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Osho AA, Dudzinski DM. Interventional Therapies for Acute Pulmonary Embolism. Surg Clin North Am 2022; 102:429-447. [DOI: 10.1016/j.suc.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [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: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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10
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Clinical factors associated with massive pulmonary embolism and PE-related adverse clinical events. Int J Cardiol 2021; 330:194-199. [PMID: 33535077 PMCID: PMC7847704 DOI: 10.1016/j.ijcard.2021.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 11/25/2022]
Abstract
Background Clinicians evaluating acute PE patients often have to identify risks for massive PE, a measure of hemodynamic instability and its consequence, massive PE related adverse clinical events (PEACE). We investigated the association of these risk factors with massive PE and PEACE in a consecutive PE cohort (n = 364). Methods Massive PE was defined as an acute central clot (proximal to the lobar artery) in a patient with right heart strain and systolic blood pressure ≤ 90 mg. PEACE was defined as any massive PE who died or required one or more of the following: ACLS, assisted ventilation, vasopressor use, thrombolytic therapy, or invasive thrombectomy, within seven days of PE diagnosis. Univariate and multivariate analysis assessing associations between the risk factors (age, gender, comorbidities, PE provoking risks, and whether the PE was felt to be idiopathic) and massive PE or PEACE were performed. Significance was determined at p < 0.05. Results Thirteen percent (n = 48) of patients presented with massive PE, and 9% (n = 32) had PEACE. In the final multivariate model, recent invasive procedure (RR = 7.4, p = 0.007), recent hospitalization (RR = 7.3, p = 0.002), and idiopathic PE (RR = 6.5, p = 0.003) were associated with massive PE. Only idiopathic PE (RR = 5.7, p = 0.005) was significantly associated with PEACE. No comorbidities or other PE provoking risks were associated with massive PE or PEACE. Conclusions As a take-home message, recent invasive procedure, recent hospitalization, and idiopathic PE were associated with massive PE, and only idiopathic PE was associated with PEACE. Simultaneously, comorbidities like age or chronic cardiopulmonary disease seem not to be associated with massive PE or PEACE.
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11
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Francis S, Kabrhel C. Current Controversies in Caring for the Critically Ill Pulmonary Embolism Patient. Emerg Med Clin North Am 2020; 38:931-944. [PMID: 32981627 DOI: 10.1016/j.emc.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Department of Surgery, Duke University Hospital, DUH Box 3096, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA. https://twitter.com/chriskabrhel
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12
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Manna S, Wruble J, Maron SZ, Toussie D, Voutsinas N, Finkelstein M, Cedillo MA, Diamond J, Eber C, Jacobi A, Chung M, Bernheim A. COVID-19: A Multimodality Review of Radiologic Techniques, Clinical Utility, and Imaging Features. Radiol Cardiothorac Imaging 2020; 2:e200210. [PMID: 33778588 PMCID: PMC7325394 DOI: 10.1148/ryct.2020200210] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/14/2020] [Accepted: 05/27/2020] [Indexed: 12/18/2022]
Abstract
In this article we will review the imaging features of coronavirus disease 2019 (COVID-19) across multiple modalities, including radiography, CT, MRI, PET/CT, and US. Given that COVID-19 primarily affects the lung parenchyma by causing pneumonia, our directive is to focus on thoracic findings associated with COVID-19. We aim to enhance radiologists' understanding of this disease to help guide diagnosis and management. Supplemental material is available for this article. © RSNA, 2020.
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Affiliation(s)
| | | | - Samuel Z. Maron
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Danielle Toussie
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Nicholas Voutsinas
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Mark Finkelstein
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Mario A. Cedillo
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Jamie Diamond
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Corey Eber
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Adam Jacobi
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Michael Chung
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
| | - Adam Bernheim
- From the Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029 (S.M., S.Z.M., D.T., N.V., M.F., M.A.C., C.E., A.J., M.C., A.B.); Complete Radiology Reading Services, Westbury, NY (J.W.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Connecticut, Farmington, Conn (J.W.); Department of Radiology and Biomedical Imaging, The Johns Hopkins Hospital, Baltimore, Md (J.W.); and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass (J.D.)
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Jia D, Li XL, Hou G, Zhou XM. A Novel Predictive Method Incorporating Parameters of Main Pulmonary Artery Bifurcation for Short-Term Prognosis in Non-high-risk Acute Pulmonary Embolism Patients. Front Physiol 2020; 11:420. [PMID: 32425813 PMCID: PMC7203501 DOI: 10.3389/fphys.2020.00420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 04/07/2020] [Indexed: 12/17/2022] Open
Abstract
The aim of this study was to build a formula to predict short-term prognosis using main pulmonary artery (MPA) parameters reconstructed from computed tomographic pulmonary angiography in non-high-risk acute pulmonary embolism (PE) patients. After reconstructing the MPA and its centerline, the MPA, the right and left pulmonary artery inlet, and the MPA outlet plane were differentiated to measure the cross-sectional area (CSA), the maximal diameter and the hydraulic diameter. The MPA bifurcation area, volume and angle were measured. MPA dilation was defined as >29 mm at the transverse section plane. The patients were randomly divided into a training set and a validation set. A least absolute shrinkage and selection operator (LASSO) logistic regression algorithm was used to build a predictive formula. The performances of the predictive formula from LASSO were tested by the area under the receiver operating characteristic curve (AUC) and precision-recall (PR) curve with 10-fold cross-validation. The clinical utility was assessed by decision curve analysis (DCA). In total, 296 patients were enrolled and randomly divided (50:50) into a training set and a validation set. The LASSO predictive formula (lambda.1SE) was as follows: 0.92 × MPA bifurcation area + 0.50 × MPA outlet hydraulic diameter + 0.10 × MPA outlet CSA. The AUCs of the predictive formula were 0.860 (95% CI: 0.795-0.912) and 0.943 (95% CI: 0.892-0.975) in the training set and validation set, respectively. The LASSO predictive formula had a higher average area under the PR curve than MPA dilation (0.71 vs. 0.23 in the training set and 0.55 vs. 0.23 in the validation set) and added a net benefit in clinical utility by DCA. Integration of MPA outlet CSA, hydraulic diameter, and bifurcation area with the LASSO predictive formula as a novel weighting method facilitated the prediction of poor short-term prognosis within 30 days after hospital admission in non-high-risk acute PE patients.
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Affiliation(s)
- Dong Jia
- Department of Emergency, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xue-Lian Li
- Department of Epidemiology, School of Public Health, China Medical University, Shenyang, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiao-Ming Zhou
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
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Dabbouseh NM, Patel JJ, Bergl PA. Role of echocardiography in managing acute pulmonary embolism. Heart 2019; 105:1785-1792. [DOI: 10.1136/heartjnl-2019-314776] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/06/2019] [Accepted: 07/22/2019] [Indexed: 12/29/2022] Open
Abstract
The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.
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Jia D, Li XL, Zhang Q, Hou G, Zhou XM, Kang J. A decision tree built with parameters obtained by computed tomographic pulmonary angiography is useful for predicting adverse outcomes in non-high-risk acute pulmonary embolism patients. Respir Res 2019; 20:187. [PMID: 31426787 PMCID: PMC6701135 DOI: 10.1186/s12931-019-1160-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/12/2019] [Indexed: 01/21/2023] Open
Abstract
Background Acute pulmonary embolism (APE) is one of the leading causes of death in cardiovascular disease. The 30-day mortality can still be 1.7–15% in non-high-risk APE patients. Some non-high-risk patients can progress into the high-risk group and even die, which is referred to as an adverse outcome. Promoting the diagnosis and predictive ability of adverse short-term prognosis was still a problem that needed to be solved. Computed tomography pulmonary angiography (CTPA) may be a way to promote the predictive ability. Our aim to develop predictive tools based on parameters obtained by computed tomographic pulmonary angiography (CTPA) in the form of a decision tree for use in non-high-risk acute pulmonary embolism (APE) patients. Methods Adverse outcome was defined within 30 days after admission to the hospital. A decision tree was built to predict adverse outcomes based on discriminating factors screened from cardiac volume and clot characteristics from recursive partitioning analysis and compared with simplified pulmonary embolism severity index (sPESI), Bova scores and risk stratification. The area under the receiver operating characteristic curve (ROC-AUC) was used to confirm the predictive ability. Results A total of 38 patients with and 303 patients without adverse outcomes were enrolled. Right ventricular/left ventricular (RV/LV) volume ratio, central pulmonary artery (CPA) embolism and right atria/left atria (RA/LA) volume ratio were used as splits in the decision tree to predict adverse outcomes in all patients. The ROC-AUC was 0.858. In CPA embolism patients, a recursive partitioning analysis was performed with cardiac volume and novel clot burden, but only the obstructing area (OA) ratio was included as a discriminating factor to build a second decision tree. The ROC-AUC for the second decision tree was 0.810. The decision trees were superior to those of sPESI, Bova scores and risk stratification, and there were no significant differences between the two decision trees. Conclusions A decision tree built by CTPA parameters can predict adverse outcomes in non-high-risk APE patients.
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Affiliation(s)
- Dong Jia
- Department of Emergency, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Xue-Lian Li
- Department of Epidemiology, School of Public Health, China Medical University, No.77, Puhe Road, Shenyang, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, No.155, Nanjing North Street, Shenyang, 110001, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, No.155, Nanjing North Street, Shenyang, 110001, China.
| | - Xiao-Ming Zhou
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, China.
| | - Jian Kang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, No.155, Nanjing North Street, Shenyang, 110001, China
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Septal bowing and pulmonary artery diameter on computed tomography pulmonary angiography are associated with short-term outcomes in patients with acute pulmonary embolism. Emerg Radiol 2019; 26:623-630. [DOI: 10.1007/s10140-019-01709-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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Prognostic value of echocardiographic parameters for right ventricular function in patients with acute non-massive pulmonary embolism. Heart Vessels 2019; 34:1187-1195. [PMID: 30671642 DOI: 10.1007/s00380-019-01340-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 01/11/2019] [Indexed: 12/19/2022]
Abstract
A prognostic value of right ventricular (RV) systolic function assessed by echocardiography in patients with acute non-massive pulmonary embolism (PE) remains controversial. The hypothesis was RV free wall strain measured using speckle-tracking echocardiography might be a powerful prognostic factor in those patients. We aimed to evaluate the prognostic value of echocardiographic measurements of RV systolic function for clinical outcomes and to assess the correlation between the echocardiographic RV function parameters in patients with acute non-massive PE. Between November 2013 and September 2016, 144 consecutive patients diagnosed as acute non-massive pulmonary embolism were prospectively enrolled and echocardiographic evaluations were performed within 1 week of diagnosis to measure various parameters of RV systolic function. The primary endpoint was in-hospital events, the composite of in-hospital PE-related death, need of additive treatments such as thrombolysis or pulmonary artery thromboembolectomy, and need of inotropics due to unstable vital sign. Among patients (mean age 60.3 ± 14.7 years, 50% female) with acute non-massive PE, the in-hospital event rate was 11.1% (16 of 144 patients). In multivariate logistic regression analysis, after adjustment of confounding factors such as age, gender, and diabetes mellitus, RV free wall strain [odd ratio (OR) 1.12, 95% confidence interval (CI) 1.04-1.21, p = 0.002] and RV global wall strain (OR 1.20, 95% CI 1.07-1.35, p = 0.002) were independent predictors for in-hospital events. The event rates were significantly different between groups classified based on RV free wall strain with cut-off value of - 15.85% (p < 0.001). RV strain assessed with speckle-tracking echocardiography is an independent prognostic marker for in-hospital events in patients with acute non-massive PE. Our results may help identify high-intermediate risk patients who need a closer monitoring.
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Kaufman AE, Pruzan AN, Hsu C, Ramachandran S, Jacobi A, Patel I, Schwocho L, Mercuri MF, Fayad ZA, Mani V. Reproducibility of thrombus volume quantification in multicenter computed tomography pulmonary angiography studies. World J Radiol 2018; 10:124-134. [PMID: 30386497 PMCID: PMC6205841 DOI: 10.4329/wjr.v10.i10.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/27/2018] [Accepted: 08/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate reproducibility of pulmonary embolism (PE) clot volume quantification using computed tomography pulmonary angiogram (CTPA) in a multicenter setting.
METHODS This study was performed using anonymized data in conformance with HIPAA and IRB Regulations (March 2015-November 2016). Anonymized CTPA data was acquired from 23 scanners from 18 imaging centers using each site’s standard PE protocol. Two independent analysts measured PE volumes using a semi-automated region-growing algorithm on an FDA-approved image analysis platform. Total thrombus volume (TTV) was calculated per patient as the primary endpoint. Secondary endpoints were individual thrombus volume (ITV), Qanadli score and modified Qanadli score per patient. Inter- and intra-observer reproducibility were assessed using intra-class correlation coefficient (ICC) and Bland-Altman analysis.
RESULTS Analyst 1 found 72 emboli in the 23 patients with a mean number of emboli of 3.13 per patient with a range of 0-11 emboli per patient. The clot volumes ranged from 0.0041 - 47.34 cm3 (mean +/- SD, 5.93 +/- 10.15cm3). On the second read, analyst 1 found the same number and distribution of emboli with a range of volumes for read 2 from 0.0041 – 45.52 cm3 (mean +/- SD, 5.42 +/- 9.53cm3). Analyst 2 found 73 emboli in the 23 patients with a mean number of emboli of 3.17 per patient with a range of 0-11 emboli per patient. The clot volumes ranged from 0.00459-46.29 cm3 (mean +/- SD, 5.91 +/- 10.06 cm3). Inter- and intra-observer variability measurements indicated excellent reproducibility of the semi-automated method for quantifying PE volume burden. ICC for all endpoints was greater than 0.95 for inter- and intra-observer analysis. Bland-Altman analysis indicated no significant biases.
CONCLUSION Semi-automated region growing algorithm for quantifying PE is reproducible using data from multiple scanners and is a suitable method for image analysis in multicenter clinical trials.
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Affiliation(s)
- Audrey E Kaufman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Alison N Pruzan
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Ching Hsu
- Daiichi Sankyo Inc., Basking Ridge, NJ 07920, United States
| | - Sarayu Ramachandran
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Adam Jacobi
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Indravadan Patel
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Daiichi Sankyo Inc., Basking Ridge, NJ 07920, United States
| | - Lee Schwocho
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Daiichi Sankyo Inc., Basking Ridge, NJ 07920, United States
| | - Michele F Mercuri
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Daiichi Sankyo Inc., Basking Ridge, NJ 07920, United States
| | - Zahi A Fayad
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Venkatesh Mani
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
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Rahaghi FN, Minhas JK, Heresi GA. Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism: New Imaging Tools and Modalities. Clin Chest Med 2018; 39:493-504. [PMID: 30122174 PMCID: PMC6317734 DOI: 10.1016/j.ccm.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Imaging continues to be the modality of choice for the diagnosis of venous thromboembolic disease, particularly when incorporated into diagnostic algorithms. Improvement in imaging techniques as well as new imaging modalities and processing methods have improved diagnostic accuracy and additionally are being leveraged in prognostication and decision making for choice of intervention. In this article, we review the role of imaging in diagnosis and prognostication of venous thromboembolism. We also discuss emerging imaging approaches that may in the near future find clinical usefulness in improving diagnosis and prognostication as well as differentiating disease phenotypes.
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Affiliation(s)
- Farbod N. Rahaghi
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School. 15 Francis Street, Boston MA 02115, ; Phone: 617-632-6770
| | - Jasleen K. Minhas
- Department of Medicine, North Shore Medical Center, 81 highland Ave Salem MA 10970, Phone: 978-354-4801
| | - Gustavo A. Heresi
- Respiratory Institute, Cleveland Clinic, Mail code A90, 9500 Euclid Ave, OH 44195, Phone: 216-636-5327
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Igneri LA, Hammer JM. Systemic Thrombolytic Therapy for Massive and Submassive Pulmonary Embolism. J Pharm Pract 2018; 33:74-89. [PMID: 29673293 DOI: 10.1177/0897190018767769] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To critically evaluate the published literature assessing the safety and efficacy of thrombolytic therapy for massive and submassive pulmonary embolism (PE). METHODS A search of human trials in the English-language (September 2017) was conducted through the MEDLINE database using the following terms: PE, tissue plasminogen activator, tenecteplase, and alteplase. 67 unique articles were identified, of which 24 clinical trials discussing clinical outcomes related to administration of either intravenous tenecteplase or alteplase were included. RESULTS Thrombolytic therapy with anticoagulation significantly reduced mortality compared to anticoagulation alone in massive PE. In submassive PE, thrombolytics reduced the rate of right ventricular dysfunction and hemodynamic collapse; however, there is an increased risk of major and minor bleeding with no benefit on long-term functional outcomes. CONCLUSIONS Patients with massive PE should receive thrombolytics when no major contraindications to therapy exist. Patients with submassive PE at highest risk for progression to hemodynamic instability should receive anticoagulation and be monitored for clinical deterioration. If an imminent risk of hemodynamic instability or cardiac arrest occurs, thrombolytics should be administered if no contraindications exist. Net mortality benefit and risk of bleeding must be considered when deciding to administer thrombolytic therapy in massive or submassive PE.
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Affiliation(s)
- Lauren A Igneri
- Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
| | - John M Hammer
- Department of Pharmacy, Carolinas Medical Center, Charlotte, NC, USA
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Kaufman AE, Pruzan AN, Hsu C, Ramachandran S, Jacobi A, Fayad ZA, Mani V. Effect of varying computed tomography acquisition and reconstruction parameters on semi-automated clot volume quantification. World J Radiol 2018; 10:24-29. [PMID: 29599936 PMCID: PMC5872394 DOI: 10.4329/wjr.v10.i3.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine effects of computed tomography (CT) image acquisition/reconstruction parameters on clot volume quantification in vitro for research method validation purposes.
METHODS This study was performed in conformance with HIPAA and IRB Regulations (March 2015-November 2016). A ten blood clot phantom was designed and scanned on a dual-energy CT scanner (SOMATOM Force, Siemens Healthcare GmBH, Erlangen, Germany) with varying pitch, iterative reconstruction, energy level and slice thickness. A range of clot and tube sizes were used in an attempt to replicate in vivo emboli found within central and segmental branches of the pulmonary arteries in patients with pulmonary emboli. Clot volume was the measured parameter and was analyzed by a single image analyst using a semi-automated region growing algorithm implemented in the FDA-approved Siemens syngo.via image analysis platform. Mixed model analysis was performed on the data.
RESULTS On the acquisition side, the continuous factor of energy showed no statistically significant effect on absolute clot volume quantification (P = 0.9898). On the other hand, when considering the fixed factor of pitch, there were statistically significant differences in clot volume quantification (P < 0.0001). On the reconstruction side, with the continuous factor of reconstruction slice thickness no statistically significant effect on absolute clot volume quantification was demonstrated (P = 0.4500). Also on the reconstruction side, with the fixed factor of using iterative reconstructions there was also no statistically significant effect on absolute clot volume quantification (P = 0.3011). In addition, there was excellent R2 correlation between the scale-measured mass of the clots both with respect to the CT measured volumes and with respect to volumes measure by the water displacement method.
CONCLUSION Aside from varying pitch, changing CT acquisition parameters and using iterative reconstructions had no significant impact on clot volume quantification with a semi-automated region growing algorithm.
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Affiliation(s)
- Audrey E Kaufman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Alison N Pruzan
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Ching Hsu
- Daiichi Sankyo Inc., Basking Ridge, NJ 07920, United States
| | - Sarayu Ramachandran
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Adam Jacobi
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Zahi A Fayad
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
| | - Venkatesh Mani
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY 10029, United States
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Zeleznik OA, Poole EM, Lindstrom S, Kraft P, Van Hylckama Vlieg A, Lasky-Su JA, Harrington L, Hagan K, Kim J, Parry B, Giordano N, Kabrhel C. Metabolomic analysis of 92 pulmonary embolism patients from a nested case-control study identifies metabolites associated with adverse clinical outcomes. J Thromb Haemost 2018; 16:500-507. [PMID: 29285876 PMCID: PMC5826867 DOI: 10.1111/jth.13937] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 02/01/2023]
Abstract
Essentials Risk-stratification often fails to predict clinical deterioration in pulmonary embolism (PE). First-ever high-throughput metabolomics analysis of risk-stratified PE patients. Changes in circulating metabolites reflect a compromised energy metabolism in PE. Metabolites play a key role in the pathophysiology and risk stratification of PE. SUMMARY Background Patients with acute pulmonary embolism (PE) exhibit wide variation in clinical presentation and outcomes. Our understanding of the pathophysiologic mechanisms differentiating low-risk and high-risk PE is limited, so current risk-stratification efforts often fail to predict clinical deterioration and are insufficient to guide management. Objectives To improve our understanding of the physiology differentiating low-risk from high-risk PE, we conducted the first-ever high-throughput metabolomics analysis (843 named metabolites) comparing PE patients across risk strata within a nested case-control study. Patients/methods We enrolled 92 patients diagnosed with acute PE and collected plasma within 24 h of PE diagnosis. We used linear regression and pathway analysis to identify metabolites and pathways associated with PE risk-strata. Results When we compared 46 low-risk with 46 intermediate/high-risk PEs, 50 metabolites were significantly different after multiple testing correction. These metabolites were enriched in the following pathways: tricarboxylic acid (TCA) cycle, fatty acid metabolism (acyl carnitine) and purine metabolism, (hypo)xanthine/inosine containing. Additionally, energy, nucleotide and amino acid pathways were downregulated in intermediate/high-risk PE patients. When we compared 28 intermediate-risk with 18 high-risk PE patients, 41 metabolites differed at a nominal P-value level. These metabolites were enriched in fatty acid metabolism (acyl cholines), and hemoglobin and porphyrin metabolism. Conclusion Our results suggest that high-throughput metabolomics can provide insight into the pathophysiology of PE. Specifically, changes in circulating metabolites reflect compromised energy metabolism in intermediate/high-risk PE patients. These findings demonstrate the important role metabolites play in the pathophysiology of PE and highlight metabolomics as a potential tool for risk stratification of PE.
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Affiliation(s)
- O. A. Zeleznik
- Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
- Harvard Medical School, Department of Medicine, Boston, United States
| | - E. M. Poole
- Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
- Harvard Medical School, Department of Medicine, Boston, United States
| | - S. Lindstrom
- University of Washington, Department of Epidemiology, Seattle, United States
- Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, Seattle, United States
| | - P. Kraft
- Harvard T.H. Chan School of Public Health, Epidemiology, Boston, United States
| | | | - J. A. Lasky-Su
- Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
| | - L.B. Harrington
- Harvard T.H. Chan School of Public Health, Nutrition, Boston, United States
| | - K. Hagan
- Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
- Harvard Medical School, Department of Medicine, Boston, United States
| | - J. Kim
- Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
- Harvard T.H. Chan School of Public Health, Epidemiology, Boston, United States
| | - B.A. Parry
- Massachusetts General Hospital, Center for Vascular Emergencies, Department of Emergency Medicine, Boston, United States
| | - N. Giordano
- Massachusetts General Hospital, Center for Vascular Emergencies, Department of Emergency Medicine, Boston, United States
| | - C. Kabrhel
- Massachusetts General Hospital, Center for Vascular Emergencies, Department of Emergency Medicine, Boston, United States
- Harvard Medical School, Department of Emergency Medicine, Boston, United States
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Abstract
Pulmonary embolism (PE) is a serious and prevalent cause of vascular disease. Nevertheless, optimal treatment for many phenotypes of PE remains uncertain. Treating PE requires appropriate risk stratification as a first step. For the highest-risk PE, presenting as shock or arrest, emergent systemic thrombolysis or embolectomy is reasonable, while for low-risk PE, anticoagulation alone is often chosen. Normotensive patients with PE but with indicia of right heart dysfunction (by biomarkers or imaging) constitute an intermediate-risk group for whom there is controversy on therapeutic strategy. Some intermediate-risk patients with PE may require urgent stabilization, and ≈10% will decompensate hemodynamically and suffer high mortality, though identifying these specific patients remains challenging. Systemic thrombolysis is a consideration, but its risks of major and intracranial hemorrhages rival overall harms from intermediate PE. Multiple hybrid pharmacomechanical approaches have been devised to capture the benefits of thrombolysis while reducing its risks, but there is limited aggregate clinical experience with such novel interventional strategies. One method to counteract uncertainty and generate a consensus multidisciplinary prognostic and therapeutic plan is through a Pulmonary Embolism Response Team, which combines expertise from interventional cardiology, interventional radiology, cardiac surgery, cardiac imaging, and critical care. Such a team can help determine which intervention-catheter-directed fibrinolysis, ultrasound-assisted thrombolysis, percutaneous mechanical thrombus fragmentation, or percutaneous or surgical embolectomy-is best suited to a particular patient. This article reviews these various modalities and the background for each.
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Affiliation(s)
- David M Dudzinski
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.).
| | - Jay Giri
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.)
| | - Kenneth Rosenfield
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.)
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Kabrhel C, Rosovsky R, Baugh C, Parry BA, Deadmon E, Kreger C, Giordano N. The creation and implementation of an outpatient pulmonary embolism treatment protocol. Hosp Pract (1995) 2017; 45:123-129. [PMID: 28402686 DOI: 10.1080/21548331.2017.1318651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The ability to rapidly and accurately risk-stratify patients with venous thromboembolism (VTE), and the availability of direct acting oral anticoagulants have reduced the need for intravenous anticoagulation for patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Emergency physicians are generally reluctant to discharge patients with VTE without defined and reliable follow up in place, and VTE patients treated with anticoagulants can be at risk for complications related to recurrent VTE and bleeding. In addition, screening for associated diseases (e.g. cancer, hypercoagulable states) may be indicated. Therefore, the outpatient treatment of low risk VTE requires coordinated effort and reliable follow up. By leveraging detailed outcome data and collaborative relationships, we have created a protocol for the safe outpatient treatment of patients with low risk DVT and PE. Our protocol is data driven and designed to address barriers to outpatient VTE management. We expect our protocol to result in improved patient satisfaction, more efficient emergency department (ED) throughput, and decreased cost. Applied nationally, the outpatient treatment of select patients with DVT and PE could have major public health and economic impact.
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Affiliation(s)
- Christopher Kabrhel
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Rachel Rosovsky
- b Division of Hematology and Oncology, Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Christopher Baugh
- c Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA
| | - Blair Alden Parry
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Erin Deadmon
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Charlotte Kreger
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Nicholas Giordano
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
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