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Adler AC. Ultrasound Rounds: Intraoperative Point-of-Care Ultrasound Identifies Intracardiac Thrombus and Pulmonary Embolism Allowing for Alteration in Surgical Management. A A Pract 2024; 18:e01796. [PMID: 38842207 DOI: 10.1213/xaa.0000000000001796] [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: 06/07/2024]
Abstract
Most of the cases demonstrating describing acute findings using point-of-care ultrasound (POCUS) have been described in emergency medicine and critical care medicine. While the use of POCUS has become more prevalent in anesthesia practice, documentation of acute findings resulting in alteration in management based on real-time ultrasound findings during pediatric anesthesia remains limited. This case highlights the use of POCUS during cardiopulmonary collapse occurring during correction of neuromuscular scoliosis. POCUS excluded the presumed diagnosis of venous air embolism and identified an intracardiac thrombus leading to the diagnosis and treatment of pulmonary embolism.
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Affiliation(s)
- Adam C Adler
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Kadri AN, Alrawashdeh R, Soufi MK, Elder AJ, Elder Z, Mohamad T, Gnall E, Elder M. Mechanical Support in High-Risk Pulmonary Embolism: Review Article. J Clin Med 2024; 13:2468. [PMID: 38730997 PMCID: PMC11084514 DOI: 10.3390/jcm13092468] [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: 02/27/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Acute pulmonary embolism (PE) may manifest with mild nonspecific symptoms or progress to a more severe hemodynamic collapse and sudden cardiac arrest. A substantial thrombotic burden can precipitate sudden right ventricular strain and failure. Traditionally, systemic thrombolytics have been employed in such scenarios; however, patients often present with contraindications, or these interventions may prove ineffective. Outcomes for this medically complex patient population are unfavorable, necessitating a compelling argument for advanced therapeutic modalities or alternative approaches. Moreover, patients frequently experience complications beyond hemodynamic instability, such as profound hypoxia and multiorgan failure, necessitating assertive early interventions to avert catastrophic consequences. The existing data on the utilization of mechanical circulatory support (MCS) devices are not exhaustive. Various options for percutaneous MCS devices exist, each possessing distinct advantages and disadvantages. There is an imminent imperative to develop a tailored approach for this high-risk patient cohort to enhance their overall outcomes.
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Affiliation(s)
- Amer N. Kadri
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Razan Alrawashdeh
- Department of Medicine, Faculty of Medicine, University of Jordan, Amman 11942, Jordan
| | - Mohamad K. Soufi
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Adam J. Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Zachary Elder
- School of Medicine, American University of Caribbean, 33027 Cupecoy, Sint Maarten
| | - Tamam Mohamad
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
| | - Eric Gnall
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Mahir Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
- Corewell Health East, Dearborn Hospital, Dearborn, MI 48124, USA
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Wilson R, Eguchi S, Orihara Y, Pfeiffer M, Peterson B, Ruzieh M, Gao Z, Gorcsan J, Boehmer J. Association between right ventricular global longitudinal strain and mortality in intermediate-risk pulmonary embolism. Echocardiography 2024; 41:e15815. [PMID: 38634182 DOI: 10.1111/echo.15815] [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: 02/05/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Right ventricular (RV) systolic dysfunction has been identified as a prognostic marker for adverse clinical events in patients presenting with acute pulmonary embolism (PE). However, challenges exist in identifying RV dysfunction using conventional echocardiography techniques. Strain echocardiography is an evolving imaging modality which measures myocardial deformation and can be used as an objective index of RV systolic function. This study evaluated RV Global Longitudinal Strain (RVGLS) in patients with intermediate risk PE as a parameter of RV dysfunction, and compared to traditional echocardiographic and CT parameters evaluating short-term mortality. METHODS Retrospective single center cohort study of 251 patients with intermediate-risk PE between 2010 and 2018. The primary outcome was all-cause mortality at 30 days. Statistical analysis evaluated each parameter comparing survivors versus non-survivors at 30 days. Receiver operating characteristic (ROC) curves and Kaplan-Meier curves were used for comparison of the two cohorts. RESULTS Altogether 251 patients were evaluated. Overall mortality rate was 12.4%. Utilizing an ROC curve, an absolute cutoff value of 17.7 for RVGLS demonstrated a sensitivity of 93% and specificity of 70% for observed 30-day mortality. Individuals with an RVGLS ≤17.7 had a 25 times higher mortality rate than those with RVGLS above 17.7 (HR 25.24, 95% CI = 6.0-106.4, p < .001). Area under the curve was (.855), RVGLS outperformed traditional echocardiographic parameters, CT findings, and cardiac biomarkers on univariable and multivariable analysis. CONCLUSIONS Reduced RVGLS values on initial echocardiographic assessment of patients with intermediate-risk PE identified patients at higher risk for mortality at 30 days.
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Affiliation(s)
- Ryan Wilson
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Shunsuke Eguchi
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Yoshiyuki Orihara
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Michael Pfeiffer
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Brandon Peterson
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mohammed Ruzieh
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainsville, Florida, USA
| | - Zhaohui Gao
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - John Gorcsan
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - John Boehmer
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
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Febra C, Santos AR, Cabrita I, Bento J, Pacheco J, Mendes M, Isidro M, Batista R, Macedo AMAFM. Comparison of diuretics and fluid expansion in the initial treatment of patients with normotensive acute pulmonary embolism: a systematic review and meta-analysis. Emerg Med J 2024; 41:187-192. [PMID: 38253364 DOI: 10.1136/emermed-2023-213525] [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: 07/24/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Right ventricular (RV) dysfunction is the main cause of death in patients with normotensive acute pulmonary embolism (PE). The optimal management for this subset of patients remains uncertain. This systematic review and meta-analysis focused on the comparison of diuretics and fluid expansion in patients with acute PE presenting with RV dysfunction and haemodynamic stability. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only RTCs. The authors searched the traditional and grey literature through 1 November 2022. Meta-analysis used open source packages in R. Inverse variance fixed-effects models with OR as the effect measure were used for primary analyses. The main outcomes defined in this review protocol included pulmonary arterial systolic pressure (PASP), creatinine value changes and N-terminal pro-B-type natriuretic peptide during the first 24 hours. RESULTS Four studies with a total of 452 patients met the inclusion criteria. The baseline characteristics of patients were similar across all studies. Overall, patients receiving diuretics had a significant 24 hours reduction in pro-B-type natriuretic peptide (standard mean difference of -41.97; 95% CI -65.79 to -18.15), and PASP (standard mean difference of -5.96; 95% CI -8.06 to -3.86). This group had significantly higher creatinine levels (standard mean difference of 7.74; 95% CI 5.04 to 10.45). The quality of the studies was heterogeneous; two had a low risk of bias, and the other two had a high risk of bias. CONCLUSIONS Very few studies have compared the efficacy and safety of diuretics and fluid expansion in normotensive patients with acute PE with RV failure. Overall, furosemide appears to reduce RV dysfunction in this subset of patients compared with fluid expansion. Further research is required to confirm these findings.
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Affiliation(s)
- Cláudia Febra
- University of Porto, Porto, Portugal
- Department of Intensive Care, Hospital da Luz, Lisboa, Lisboa, Portugal
| | - Ana Rita Santos
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Isabel Cabrita
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Joana Bento
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - João Pacheco
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Mariana Mendes
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Michael Isidro
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Rafael Batista
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
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Yuriditsky E, Horowitz JM, Taslakian B, Saric M. Saddle Pulmonary Embolism Detected by Transthoracic Echocardiography in a Patient With Suspected Myocardial Infarction. CASE (PHILADELPHIA, PA.) 2024; 8:54-57. [PMID: 38425574 PMCID: PMC10899716 DOI: 10.1016/j.case.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
•PE is very rarely identified on TTE. •Saddle PE does not represent a higher-risk subset of PE. •Catheter-based therapies are becoming more commonplace in the management of acute PE.
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Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York
| | - James M. Horowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York
| | - Bedros Taslakian
- Division of Vascular and Interventional Radiology, Department of Radiology, NYU Langone Health, New York, New York
| | - Muhamed Saric
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York
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Murphy SP, Urbut SM, Dudzinski DM. Progress Toward Prognosis in Patients With Pulmonary Embolism. J Am Soc Echocardiogr 2023; 36:941-944. [PMID: 37480876 DOI: 10.1016/j.echo.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Sean P Murphy
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sarah M Urbut
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David M Dudzinski
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Cardiac Intensive Care Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Pulmonary Embolism Response Team, Center for Vascular Emergencies, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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