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Patel R, Mistry AM, Mulukutla V, Prajapati K. Right Ventricle Thrombus in the Setting of Submassive Pulmonary Embolism. Cureus 2023; 15:e41161. [PMID: 37525768 PMCID: PMC10387165 DOI: 10.7759/cureus.41161] [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] [Accepted: 06/29/2023] [Indexed: 08/02/2023] Open
Abstract
Submassive pulmonary embolism (PE) with right heart strain and right ventricle thrombus is a complex and potentially life-threatening condition. Prompt recognition and management are crucial to optimizing patient outcomes. We present the case of a 59-year-old male with a history of obstructive sleep apnea (OSA) and non-compliance with continuous positive airway pressure (CPAP) therapy who presented with progressively worsening shortness of breath (SOB). Imaging studies revealed bilateral submassive PE with right heart strain and a thrombus in the right ventricle. Treatment included anticoagulation therapy and mechanical thrombectomy using the INARI FlowTriever device. This case highlights the importance of early recognition and risk factor assessment, such as using testosterone boosters, considering right ventricle thrombus as a complication of PE, and the role of mechanical thrombectomy in selected cases.
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Affiliation(s)
- Rutul Patel
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Anuja Mahesh Mistry
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | | | - Krupal Prajapati
- Internal Medicine, Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
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2
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Ali L, Sharif M, Naqvi SGA, Mohammed I, Baig MA, Sidratul Muntaha K, Chalil AR, Ali H, Aweida HA, Iqrar A. To Study the Correlation of Clinical Severity and Cytokine Storm in COVID-19 Pulmonary Embolism Patients by Using Computed Tomography Pulmonary Angiography (CTPA) Qanadli Clot Burden Scoring System. Cureus 2023; 15:e39263. [PMID: 37342749 PMCID: PMC10278873 DOI: 10.7759/cureus.39263] [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] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a fatal form of venous thromboembolism (VTE), with an overall untreated mortality of up to 30%. Greater than 50% of patients with lower extremity proximal DVT have concurrent PE at presentation. VTE has been seen in up to one-third of patients with COVID-19 infections requiring intensive care unit (ICU) admission. The objective of this study is to determine the correlation between CT pulmonary angiography, pulmonary embolism clot burden, and the Qanadli scoring system with clinically severe COVID-19 pneumonia and cytokine storm. MATERIAL AND METHOD 153 COVID-19 hospitalized patients who underwent CT pulmonary angiography (CTPA) for likely PE on pretest probability modified Wells criteria were enrolled. COVID-19 pneumonia was classified as URTI (upper respiratory tract infection), mild, severe, and critical COVID pneumonia. For data analysis, we categorized into two groups: (1) the non-severe group included URTI and mild pneumonia, and (2) the severe group included severe and critical pneumonia. We used the Qanadli scoring system to assess the PE percentages of pulmonary vascular obstruction using CTPA. Results: 41.8% (64) of COVID-19 patients were diagnosed with pulmonary embolism (PE) on CTPA. The majority of 51.6% of pulmonary vascular occlusions using the Qanadli scoring system for pulmonary embolism were at segmental arterial levels. Out of 104 COVID-19 cytokine storm patients, 45 (43%) were associated with pulmonary embolism. Overall, a 25% (16) mortality rate was observed in COVID-19 patients with pulmonary embolism. DISCUSSION The pathogenesis of hypercoagulability in COVID-19 may include direct endothelial cell invasion by the virus, microvascular inflammation, endothelial exocytosis, and endotheliitis. A meta-analysis of 71 studies to investigate the occurrence of PE on CTPA in COVID-19 patients found 48.6% in ICU settings and 65.3% of patients have clots in the peripheral pulmonary vasculature. CONCLUSIONS There is a significant correlation between pulmonary embolism and high clot burden Qanadli CTPA scores, as well as between the severity of COVID-19 pneumonia and mortality. The association between critically ill COVID-19 pneumonia and pulmonary embolism may result in higher mortality and a poor prognostic marker.
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Affiliation(s)
- Liaquat Ali
- Neurology, Hamad General Hospital, Doha, QAT
- Neurology, Weill Cornell Medicine-Qatar, Doha, QAT
| | | | | | | | | | | | | | - Hanna Ali
- Medicine, Hamad General Hospital, Doha, QAT
| | | | - Ambreen Iqrar
- Neurology, Aga Khan University Hospital, Karachi, PAK
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3
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Yılmaz F, Tekin Y, Toprak N, Eyı̇nç MB, Arslan ED. A case of massive pulmonary embolism causing cardiac arrest managed with successful systemic thrombolytic in the emergency department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pulmonary Embolism (PE), when complicated by cardiac arrest, is almost always fatal despite all resuscitative efforts. However, a more favorable is possible when PE is rapidly identified as the cause of cardiac arrest and pulmonary circulation is quickly re-established by specific therapy. A 54-year-old woman was brought to the Emergency Department (ED) by 112 emergency ambulance service with the complaint of shortness of breath that had started 2 hours ago. She developed cardiac arrest while being physical examined 2 minutes after admission, and Cardiopulmonary Resuscitation (CPR) was immediately begun. Massive PE was considered the most likely diagnosis in the light of her history, physical examined, and bedside ultrasonography findings; thus, recombinant tissue Plasminogen Activator (r-tPA) was administered during CPR. The second CPR attempt achieved return of spontaneous circulation within 5 minutes. She was treated at intensive care unit for 32 days and discharged from the hospital with complete recovery.
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Pan J, Zhou X, Xu Z, Chen B. Successful management of hemodynamic instability secondary to saddle pulmonary embolism-induced cardiac arrest using VA-ECMO in advanced malignancy with brain metastases. J Cardiothorac Surg 2022; 17:296. [PMID: 36471400 PMCID: PMC9720990 DOI: 10.1186/s13019-022-02044-w] [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: 06/13/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Saddle pulmonary embolism (SPE) represents a rare type of venous thromboembolism that frequently causes circulation collapse and sudden death. While venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been well established as a salvage treatment for SPE-induced circulatory shock, it is infrequently administered in patients with advanced malignancy, especially those with brain metastases, given the potential bleeding complications and an uncertain prognosis. As far, there are rare case reports regarding the successful management of hemodynamic instability secondary to SPE-induced cardiac arrest using VA-ECMO in advanced malignancy patients with brain metastases. CASE PRESENTATION A 65-year-old woman presenting with cough and waist discomfort who had a history of lung cancer with brain metastases was admitted to the hospital to receive chemoradiotherapy. She suffered sudden cardiac arrest during hospitalization and returned to spontaneous circulation after receiving a 10-min high-quality cardiopulmonary resuscitation. Pulmonary embolism was suspected due to the collapsed hemodynamics and a distended right ventricle identified by echocardiography. Subsequent computed tomographic pulmonary angiography revealed a massive saddle thrombus straddling the bifurcation of the pulmonary trunk. VA-ECMO with adjusted-dose systemic heparinization was initiated to rescue the unstable hemodynamics despite receiving thrombolytic therapy with alteplase. Immediately afterward, the hemodynamic status of the patient stabilized rapidly. VA-ECMO was successfully discontinued within 72 h of initiation without any clotting or bleeding complications. She was weaned off invasive mechanical ventilation on the 6th day of intensive care unit (ICU) admission and discharged from the ICU 3 days later with good neurological function. CONCLUSION VA-ECMO may be a 'bridging' therapy to circulation recovery during reperfusion therapy for SPE-induced hemodynamic collapse in malignancy patients with brain metastases.
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Affiliation(s)
- Jianneng Pan
- grid.9227.e0000000119573309Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000 Zhejiang China
| | - Xiaoyang Zhou
- grid.9227.e0000000119573309Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000 Zhejiang China
| | - Zhaojun Xu
- grid.9227.e0000000119573309Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000 Zhejiang China
| | - Bixin Chen
- grid.9227.e0000000119573309Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000 Zhejiang China
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5
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Pandompatam G, Qaseem M. A 55-Year-Old Man With Progressive Shortness of Breath. Chest 2022; 162:e321-e323. [PMID: 36494133 PMCID: PMC9723272 DOI: 10.1016/j.chest.2021.12.676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/22/2021] [Accepted: 12/01/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Govind Pandompatam
- Department of Critical Care, HSHS Saint John's Hospital, Springfield, IL.
| | - Muhammad Qaseem
- Department of Critical Care, HSHS Saint John's Hospital, Springfield, IL
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6
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Muacevic A, Adler JR. Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective. Cureus 2022; 14:e29885. [PMID: 36348926 PMCID: PMC9629997 DOI: 10.7759/cureus.29885] [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] [Accepted: 09/25/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Saddle pulmonary embolism (PE) is a type of central PE that involves the bifurcation of the pulmonary arteries. First-line treatment is usually systemic thrombolytics, but surgical and mechanical thrombectomy (ST and MT) are used for patients with contraindications to thrombolytics or right heart strain. This study compares surgical and mechanical thrombectomy trends and outcomes in patients with saddle PE. Methods The data was extracted from the National In-Patient Sample (NIS) from 2016-2018 using the International Classification of Diseases-10-Clinical Modification (ICD-10-CM) diagnosis codes. We used the Cochrane-Armitage trend test to analyze the trends of ST and MT and the chi-square test for statistical analyses. A two-tailed p-value of <0.05 was considered statistically significant. Results The overall trend of MT in saddle PE rose from 2016 to 2018, while ST remained stable. Around 95% of patients undergoing ST/MT were emergent admissions, with 82.5% occurring in teaching hospitals. Patients of age >65 years and more with comorbidity burdens were more likely to undergo MT over ST. In-hospital mortality after ST was 15.1%, and after MT was 11.1% (p:<0.001). The most common complications after ST were congestive heart failure (CHF) and atrial fibrillation (AF), and after MT were vascular events and CHF. Conclusion The use of mechanical thrombectomy has steadily increased during the study period. ST is more common in large/teaching hospitals, weekend admissions, and patients transferred from other facilities. MT is more common in elderly patients with a higher comorbidity burden. Patients who underwent MT had lower mortality, length of hospital stay, and post-procedural complications.
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7
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Kimura S, Takahashi K, Kaneyasu H, Fujimoto Y, Ohta N, Okada S, Hasegawa S. Successful Treatment of Saddle Pulmonary Thromboembolism in 23-Week Preterm Infant. Int Heart J 2022; 63:989-994. [PMID: 36104227 DOI: 10.1536/ihj.21-838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Saddle pulmonary thromboembolism (PTE) is defined as a thromboembolism straddling the bifurcation of the main pulmonary artery trunk and it is rarely seen in extremely low birth weight infants (ELBWI). Saddle PTE is a critical disease that requires urgent treatment. However, the treatment guidelines for ELBWI are not established. We present the case of a 1-day-old preterm infant (gestational age 23 weeks) who showed sudden desaturation and pulmonary hypertension due to saddle PTE. A thrombus was observed in the bifurcation of the pulmonary artery. The blood flow to the pulmonary artery on the left side was interrupted, and the right side showed severe stenosis. Since the patient was an ELBWI in the acute phase, we decided to use recombinant tissue plasminogen activator (rt-PA) and administered a maintenance dose (0.08 mg/kg/hour), instead of the loading dose. After using rt-PA, the thrombus dissolved in 8 hours without adverse events. This case suggests that starting with a maintenance dose of rt-PA may be an effective treatment option for saddle PTE in ELBWI in the acute phase under the high risk of bleeding.
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Affiliation(s)
- Sasagu Kimura
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Kazumasa Takahashi
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Hidenobu Kaneyasu
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Yousuke Fujimoto
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Naoki Ohta
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Seigo Okada
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Shunji Hasegawa
- General Perinatal Medical Center, Yamaguchi University Hospital.,Department of Pediatrics, Yamaguchi University Graduate School of Medicine
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8
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Borisoff BD, Bohn KD, Sager J, Gracious BL. Unprovoked Submassive Saddle Pulmonary Embolism in an Adult Male After Pfizer COVID-19 Vaccination. Cureus 2022; 14:e27717. [PMID: 35949450 PMCID: PMC9356667 DOI: 10.7759/cureus.27717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/05/2022] Open
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9
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Aramberri M, Benegas M, Sanchez M, Muñoz-Guglielmetti D, Zamora C, García-Villa A, Diaz-Pedroche C, Font C. Saddle Pulmonary Embolism in Patients with Cancer in the Era of Incidental Events: Clinical Findings and Outcomes in a Single Centre Cohort. TH OPEN 2022; 6:e267-e275. [PMID: 36299808 PMCID: PMC9800169 DOI: 10.1055/s-0042-1755605] [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: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer. Objectives This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events. Patients/Methods Consecutive patients with cancer-related PE (March 1, 2006-October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE. Results Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%; p =0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%; p =0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%; p <0.001) and interventricular septum displacement (53 vs. 20%; p <0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE. Conclusion Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.
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Affiliation(s)
- Mario Aramberri
- Department of Internal Medicine, Hospital de Galdakao-Usansolo, Galdakao, Spain
| | - Mariana Benegas
- Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marcelo Sanchez
- Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Carles Zamora
- Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Adrián García-Villa
- Department of Internal Medicine, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Carmen Diaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carme Font
- Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
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10
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Doodnauth AV, Choi CS, Dunkley JC, Zharovsky EM, Nguyen TM, Murkami N. Acute Saddle Embolus With Thrombus in Transit: A Case Report and Review of the Literature. Cureus 2022; 14:e25018. [PMID: 35719788 PMCID: PMC9198286 DOI: 10.7759/cureus.25018] [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] [Accepted: 05/14/2022] [Indexed: 12/03/2022] Open
Abstract
Pulmonary embolism is a life-threatening medical emergency associated with right ventricular failure. Rarely, it impacts the left ventricle to the point of compromising the left ventricular (LV) ejection fraction. We present a case of a 73-year-old African American male with a medical history pertinent for intravascular large B-cell lymphoma who developed an acute saddle embolus with a “clot-in-transit” and profound LV systolic dysfunction. Our report illustrates how an acute saddle embolus may be associated with LV systolic dysfunction via the “reverse Bernheim effect.” Additionally, the report highlights the significance of a “clot-in-transit” and LV systolic dysfunction, as they both directly correlate with increased risk of mortality.
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11
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Ibrahim WH, Al-Shokri SD, Hussein MS, Kamel A, Abu Afifeh LM, Karuppasamy G, Parambil JV, Elasad FM, Abdelghani MS, Abdellah A, Faris ME. Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics. Libyan J Med 2022; 17:2044597. [PMID: 35227164 PMCID: PMC8890508 DOI: 10.1080/19932820.2022.2044597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P= .001), and tachypnea (58.9% vs. 42.1%, P= .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P= .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P= .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P= .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P= .000), RV dysfunction (45.8% vs. 22%, P= .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P= .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P= .864) and hypoxemia (41.1% vs. 34.3%, P= .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.
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Affiliation(s)
- Wanis H Ibrahim
- Department of Medicine, Hamad General Hospital, Clinical Medicine, Qatar University and Weill-Cornell Medicine Doha Qatar
| | - Shaikha D Al-Shokri
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Musa S Hussein
- Department of Medicine, Hamad General Hospital, Doha, Qatar
| | | | | | | | - Jessiya V Parambil
- ST3 General Medicine, Milton Keynes University Hospital NHS, Milton Keynes, UK
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Nahidi SM, Ali U, Duka L, Fuentes-Rosales JC, Bhatt U. Incidental Finding of Saddle Pulmonary Embolism on a CT Scan of the Abdomen and Pelvis in a Patient With Adenocarcinoma of the Colon. Cureus 2021; 13:e20757. [PMID: 34984163 PMCID: PMC8714042 DOI: 10.7759/cureus.20757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 12/29/2022] Open
Abstract
A saddle pulmonary embolism is defined as a large thromboembolus lodged at the bifurcation of the pulmonary artery. It would be expected for a patient with a saddle pulmonary embolism to present with symptoms such as dyspnea or pleuritic pain. However, more often than not, saddle pulmonary embolisms may present asymptomatically and are not associated with the typical symptoms. We present a case of an incidental finding of saddle pulmonary embolism in an 89-year-old patient with a past medical history significant of gastrointestinal adenocarcinoma that was treated with capecitabine. The saddle pulmonary embolism was found incidentally on computer tomography (CT) with the contrast of the abdomen and subsequently confirmed with CT of the chest with contrast. It is crucial to be mindful of a possible pulmonary embolism in a patient with similar past medical history.
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Abstract
Saddle pulmonary embolism is an uncommon type of venous thromboembolism that can lead to sudden hemodynamic collapse and death. Saddle pulmonary embolism can be difficult to recognize, and data on its presentation, clinical features, and associated complications are sparse. We sought to characterize patients with saddle pulmonary embolism. DESIGN The Montage software (Nuance, Burlington, MA) was used to identify patients to create a retrospective cohort study. SETTING Montefiore Medical Center from January 1, 2012, to December 31, 2018. PATIENTS All subjects diagnosed with saddle pulmonary embolism in above time period. INTERVENTIONS Charts were reviewed for demographics, diagnostics, laboratory data, presenting vital signs, inhospital mortality, 6-month survival, and prevalence of recurrent venous thromboembolism. MEASUREMENTS AND MAIN RESULTS About 120 patients with saddle pulmonary embolism were identified. Median age was 61 years and 57.5% were women. Events were provoked by a transient risk factor in 43.3%. On presentation, median mean arterial pressures were normal (93 mm Hg). Only five of 120 of patients (4.2%) presented with vitals concerning for massive pulmonary embolism. We found a 9.2% inhospital mortality; an additional 8.6% died within 6 months of discharge. Inhospital mortality was higher in women (11.6%), compared with men (3.9%), but this was not significant (p = 0.28). In 10 patients, both ventilation/perfusion scans and computed tomography pulmonary angiogram were performed. None of the ventilation/perfusion scans diagnosed saddle pulmonary embolism. Thrombus was visualized in the right heart in eight of 105 (7.6%), and this group had a higher inhospital mortality (37.5%). Recurrent venous thromboembolism occurred in 13 of 85 of survivors (15.3%). CONCLUSIONS Despite presenting without the accepted clinical criteria for massive pulmonary embolism, saddle pulmonary embolism has a very high inhospital mortality. Ventilation/perfusion scan is unable to diagnose saddle pulmonary embolism. Visualized right heart thrombi portend an even higher inhospital mortality.
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14
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Alshumrani G, Al bshabshe A, Mousa WF. Diagnostic yield of CT pulmonary angiography for pulmonary embolism in clinically suspected patients. Medicine (Baltimore) 2021; 100:e26213. [PMID: 34087898 PMCID: PMC8183708 DOI: 10.1097/md.0000000000026213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/17/2021] [Indexed: 01/04/2023] Open
Abstract
Pulmonary embolism (PE) is a common medical problem. Its diagnostic criteria must be reviewed to determine the need for confirmatory testing. Computed tomography pulmonary angiography (CTPA) is the current standard of care, which provides accurate diagnosis with rapid turnaround. This study aimed to estimate the diagnostic yield of CTPA in clinically suspected PE patients in a tertiary care hospital in Saudi Arabia.Radiology records of all patients with clinically suspected PE who underwent CTPA between January 1, 2012 and September 30, 2018 were reviewed retrospectively. A radiologist with 10 years of professional experience interpreted and reported all cases. The Wells score with 2 tiers (likely and unlikely) was used to raise the clinical suspicion of PE.Positive results for PE were reported in 177 out of 534 clinically suspected cases (33%). Among the positive PE cases, 143 were acute (81%) and 34 (19%) were chronic. Bilateral, right-sided, and left-sided PE were found in 115 (65%), 37 (21%), and 25 (14%) cases, respectively. Involvement of the segmental branches, subsegmental branches, and the pulmonary trunk were noted in 152 (86%), 70 (40%), and 9 cases (5%), respectively. Saddle PE was found in (4%) of the cases. The lower lobe branches (right 55%, left 53%) and the upper lobe branches (right 47%, left 41%) were the most common sites of involvement.CTPA had a higher positive detection rate for PE among clinically suspected cases than its published diagnostic yield. Adequate clinical evaluation when selecting patients for CTPA is emphasized to minimize unjustified exposure of the patients to radiation and intravenous contrast administration. It is crucial for radiologists to provide detailed reports commenting on all relevant findings, including pertinent negatives. A template for reporting radiological findings for CTPA can be recommended for this purpose.
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Affiliation(s)
| | - Ali Al bshabshe
- Department of Medicine (Adult Critical Care Division), College of Medicine, King Khalid University, Abha
| | - Wesam Faried Mousa
- Department of Critical Care, Khamis General Hospital, Khamis Mushyet, Saudi Arabia
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15
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Chong WH, Saha BK, Wang C, Beegle S. Type A aortic dissection mimicking saddle pulmonary embolism on CT imaging. J Am Coll Emerg Physicians Open 2020; 1:132-136. [PMID: 33000025 PMCID: PMC7493540 DOI: 10.1002/emp2.12026] [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: 12/21/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 11/12/2022] Open
Abstract
Type A aortic dissection is an uncommon cause of chest pain that carries a high morbidity and mortality rate. A previous history of hypertension and coronary artery bypass grating (CABG) are recognized risk factors for Type A aortic dissection. We present a case of an elderly man who presents with acute onset chest pain and was found to have an acute ruptured Type A aortic dissection that has a "saddle pulmonary embolism"-like appearance on computed tomography (CT) imaging. We also describe the clinical, laboratory, and radiological workup done leading up to the diagnosis of Type A aortic dissection in the emergency setting.
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Affiliation(s)
- Woon H. Chong
- Department of Pulmonary and Critical CareAlbany Medical CenterAlbanyNew York
| | - Biplab K. Saha
- Department of Pulmonary and Critical CareOzarks Medical CenterWest PlainsMissouri
| | - Christopher Wang
- Department of Pulmonary and Critical CareAlbany Medical CenterAlbanyNew York
| | - Scott Beegle
- Department of Pulmonary and Critical CareAlbany Medical CenterAlbanyNew York
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Cleveland Manchanda EC, Kharasch SJ, Liteplo AS. Dyspnea in an Otherwise Healthy 18-year-old: The Importance of Point-of-care Ultrasonography. Clin Pract Cases Emerg Med 2019; 3:271-274. [PMID: 31404178 PMCID: PMC6682241 DOI: 10.5811/cpcem.2018.9.39218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/23/2018] [Accepted: 09/06/2018] [Indexed: 11/11/2022] Open
Abstract
A healthy 18-year-old male presented to the emergency department with chest pain, palpitations, and dyspnea. His exam was unremarkable; however, point-of-care ultrasound (POCUS) revealed right ventricular strain with a D-sign and enlarged right ventricle. He subsequently reported a history of factor V Leiden. His D-dimer was markedly elevated, and a computed tomography angiogram of the chest demonstrated submassive pulmonary embolism (PE). He was taken to the catheterization lab for directed thrombolysis and was discharged in good condition two days later. Factor V Leiden is the most common genetic cause of venous thromboembolism. POCUS can facilitate rapid diagnosis and risk stratification of patients with acute PE.
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Affiliation(s)
| | - Sigmund J Kharasch
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Andrew S Liteplo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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17
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Saddle pulmonary embolism and in-hospital mortality in patients with cancer. Int J Clin Oncol 2019; 24:727-730. [DOI: 10.1007/s10147-019-01406-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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18
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Li H, Jen S, Agarwal S, Rotem E. Management of cardiac tamponade during catheter-directed thrombolysis of saddle pulmonary embolism: A clinical dilemma. Lung India 2018; 35:336-338. [PMID: 29970775 PMCID: PMC6034378 DOI: 10.4103/lungindia.lungindia_383_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Catheter-directed thrombolysis (CDT) for the treatment of acute pulmonary embolism (PE) has gained popularity in recent years, but potential complications during the procedure and their management are not frequently discussed in the literature. In this case report, we describe the clinical dilemma regarding the postoperative anticoagulation management of a 60-year-old male who developed cardiac perforation during a CDT of an acute saddle PE. Early resumption of systemic heparin in such cases may help in clot resolution; however, it can worsen the hemopericardium. On the other hand, delaying restarting heparin may help in healing of the cardiac perforation but can lead to clot propagation. As the chest tube output was minimal initially, anticoagulation was started, which, however, led to disastrous outcome. With limited published medical literature to help guide such a complex situation, it may be prudent to carefully weigh the risks and benefits of resuming systemic heparin versus delaying it for 1–2 days to allow for definitive resolution of the cardiac perforation.
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Affiliation(s)
- Hanzhou Li
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Serena Jen
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shvetank Agarwal
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Eran Rotem
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Zuin M, Rigatelli G, Zonzin P, Casazza F, Roncon L. Saddle pulmonary embolism in hemodynamically stable patients: To lyse or not to lyse? An issue in no guidelines land. Eur J Intern Med 2017; 46:e26-e28. [PMID: 28888330 DOI: 10.1016/j.ejim.2017.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 09/04/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy; Department of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Section of Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy
| | - Pietro Zonzin
- Department of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, Milan, Italy
| | - Loris Roncon
- Department of Cardiology, Rovigo General Hospital, Rovigo, Italy.
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Alkinj B, Pannu BS, Apala DR, Kotecha A, Kashyap R, Iyer VN. Saddle vs Nonsaddle Pulmonary Embolism: Clinical Presentation, Hemodynamics, Management, and Outcomes. Mayo Clin Proc 2017; 92:1511-1518. [PMID: 28890217 DOI: 10.1016/j.mayocp.2017.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/25/2017] [Accepted: 07/18/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To understand the clinical significance, hemodynamic presentation, management, and outcomes of patients presenting with saddle pulmonary embolism (PE). METHODS All patients with saddle PE diagnosed at Mayo Clinic in Rochester, Minnesota, from January 1, 1999, through December 31, 2014, were included in this study. These patients were age and simplified Pulmonary Embolism Severity Index (sPESI) matched (1:1) to a nonsaddle PE cohort. Both groups were then classified into massive, submassive, and low-risk PE based on established criteria and compared for clinical presentation, management, and outcomes. RESULTS A total of 187 consecutive patients with saddle PE were identified. The saddle PE group presented more frequently with massive PE (31% vs 20%) and submassive PE (49% vs 32%), whereas low-risk PE was more common in the nonsaddle PE group (48% vs 20%). Systemic thrombolysis was used more frequently in the saddle PE group on admission (10% vs 4%; P=.04) and later during hospitalization (3.2% vs 0%; P=.03). Late major adverse events were similar in both groups except for mechanical ventilation (6% in saddle PE vs 1% in nonsaddle PE; P=.02). Overall in-hospital mortality did not differ between the 2 groups (4.3% in saddle PE vs 5.4% in nonsaddle PE; P=.81). CONCLUSION Although patients with saddle PE presented with higher rates of hemodynamic compromise and need for thrombolysis and mechanical ventilation, we found no difference in short-term outcomes compared with an age- and severity-matched nonsaddle PE cohort. Overall, in-hospital mortality was low in both groups.
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Affiliation(s)
- Bashar Alkinj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bibek S Pannu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Dinesh R Apala
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Aditya Kotecha
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Computed Tomographic Pulmonary Angiographic Findings Can Predict Short-Term Mortality of Saddle Pulmonary Embolism: A Retrospective Multicenter Study. J Comput Assist Tomogr 2017; 40:327-34. [PMID: 26953764 DOI: 10.1097/rct.0000000000000373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In patients with saddle pulmonary embolism (PE), the correlation between computed tomographic pulmonary angiographic (CTPA) findings and short-term outcome remains unclear. The purpose is to determine if CTPA findings predict 1-month mortality of patients with saddle PE. METHODS This is a multicenter, retrospective study of saddle PE. Computed tomographic pulmonary angiographic findings of 115 consecutive patients (male-to-female ratio, 65:50; mean age, 64.3 ± 16.3 years) with saddle PE were evaluated. One-month mortality after diagnosis was the primary end point. RESULTS Twenty-four patients died within 1 month. Among CTPA findings, quantitative parameters including right/left ventricular area ratios (RVa/LVa), right/left atrial diameter ratios, Cobb angle, and Mastora score were significantly enlarged in survivors. Also, qualitative findings including contrast agent reflux into the azygos vein and pericardial effusion were significantly different between survivors and nonsurvivors. Areas under the curve on receiver operating characteristic curves revealed the cutoff values for predicting early mortality of saddle PE using right/left atrial diameter ratios, RVa/LVa, Mastora score, and Cobb angle, respectively, were 2.15, 2.00, 69%, and 58°. Logistic regression analysis suggested that both RVa/LVa (odds ratio, 5.100; P = 0.0004) and Cobb angle (odds ratio, 1.596; P = 0.0321) were independent predictors of early mortality. The combination of RVa/LVa and Cobb angle increased the area under the curve to 0.882, but the difference did not reach significance compared with RVa/LVa or Cobb angle, alone (P > 0.05). CONCLUSION In patients with saddle PE, RVa/LVa and Cobb angle seem valuable in predicting short-term mortality.
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Secko M, Legome E, Rinnert S. Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest. Am J Emerg Med 2016; 34:2467.e1-2467.e2. [PMID: 27318744 DOI: 10.1016/j.ajem.2016.06.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/04/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- Michael Secko
- Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203.
| | - Eric Legome
- Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203
| | - Stephan Rinnert
- Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203
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Aviram G, Soikher E, Bendet A, Ziv-Baran T, Berliner S, Shmueli H, Friedensohn L, Milwidsky A, Sadovnik O, Topilsky Y. Automatic assessment of cardiac load due to acute pulmonary embolism: Saddle vs. central and peripheral emboli distribution. Heart Lung 2016; 45:261-9. [DOI: 10.1016/j.hrtlng.2016.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/20/2016] [Accepted: 01/26/2016] [Indexed: 01/29/2023]
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Liu M, Miao R, Guo X, Zhu L, Zhang H, Hou Q, Guo Y, Yang Y. Saddle Pulmonary Embolism: Laboratory and Computed Tomographic Pulmonary Angiographic Findings to Predict Short-term Mortality. Heart Lung Circ 2016; 26:134-142. [PMID: 27132624 DOI: 10.1016/j.hlc.2016.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/12/2015] [Accepted: 02/14/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Saddle pulmonary embolism (SPE) is rare type of acute pulmonary embolism and there is debate about its treatment and prognosis. Our aim is to assess laboratory and computed tomographic pulmonary angiographic (CTPA) findings to predict short-term mortality in patients with SPE. METHODS This was a five-centre, retrospective study. The clinical information, laboratory and CTPA findings of 88 consecutive patients with SPE were collected. One-month mortality after diagnosis of SPE was the primary end-point. The correlation of laboratory and CTPA findings with one-month mortality was analysed with area under curve (AUC) of receiver operating characteristic (ROC) curves and logistic regression analysis. RESULTS Eighteen patients with SPE died within one month. Receiver operating characteristic curves revealed that the cutoff values for the right and left atrial diameter ratio, the right ventricular area and left ventricular area ratio (RVa/LVa ratio), Mastora score, septal angle, N-terminal pro-brain natriuretic peptide and cardiac troponin I (cTnI) for detecting early mortality were 2.15, 2.13, 69%, 57°, 3036 pg/mL and 0.18ng/mL, respectively. Using logistic regression analysis of laboratory and CTPA findings with regard to one-month mortality of SPE, RVa/LVa ratio and cTnI were shown to be independently associated with early death. A combination of cTnI and RVa/LVa ratio revealed an increase in the AUC value, but the difference did not reach significance compared with RVa/LVa or cTnI, alone (P>0.05). CONCLUSION In patients with SPE, both the RVa/LVa ratio on CTPA and cTnI appear valuable for the prediction of short-term mortality.
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Affiliation(s)
- Min Liu
- Department of Radiology, Beijing Chaoyang Hospital of Capital Medical University, Beijing 100020, China.
| | - Ran Miao
- Clinical Laboratory, Beijing Chaoyang Hospital of Captial Medical Univerisity, Beijing, 100020, China
| | - Xiaojuan Guo
- Department of Radiology, Beijing Chaoyang Hospital of Capital Medical University, Beijing 100020, China
| | - Li Zhu
- Li Zhu, Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Hongxia Zhang
- Department of Radiology, China Rehabilitation Research Center of Capital Medical University, Beijing 100068, China
| | - Qing Hou
- Department of Radiology, Beijing Pu Ren Hospital, Beijing 100062, China
| | - Youmin Guo
- Department of Radiology First Affiliated Hospital of Medical College of Xi'an JiaoTong University, Xi'an Shannxi, 710061, China
| | - Yuanhua Yang
- Respiratory Diseases Research Center, Beijing Chaoyang Hospital of Capital Medical University, Beijing 100020, China
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Newman J, Park D, Manetta F. Extracorporeal membrane oxygenation for failed tPA therapy of pulmonary embolism. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/2055552016633964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Pulmonary embolism may cause cardiac arrest secondary to obstruction of blood flow. Traditional treatment strategies include anticoagulation, thrombolysis, and mechanical extraction. Some advocate for support with extra corporeal membrane oxygenation; however, surgical therapies are contraindicated following thrombolytics. Methods: We describe the emergent use of peripheral extra corporeal membrane oxygenation following thrombolytic therapy for a saddle pulmonary embolism associated with multiple episodes of cardiac arrest. Results: The patient was stabilized with peripheral extra corporeal membrane oxygenation, anticoagulated and subsequently weaned from extra corporeal membrane oxygenation without any major bleeding complications. Conclusion: The administration of thrombolytics should not be a contraindication for extra corporeal membrane oxygenation in patients with massive pulmonary embolism associated with hemodynamic instability.
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Affiliation(s)
- Joshua Newman
- Hofstra North Shore-LIJ School of Medicine, Hofstra University, Hempstead, NY, USA
| | - David Park
- Department of Cardiovascular and Thoracic Surgery, Southside Hospital, Bay Shore, NY, USA
| | - Frank Manetta
- Hofstra North Shore-LIJ School of Medicine, Hofstra University, Hempstead, NY, USA
- Department of Cardiovascular and Thoracic Surgery, Southside Hospital, Bay Shore, NY, USA
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Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism. Ann Am Thorac Soc 2016; 12:666-73. [PMID: 25695933 DOI: 10.1513/annalsats.201411-548oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. OBJECTIVES To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. METHODS We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. MEASUREMENTS AND MAIN RESULTS Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. CONCLUSIONS Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.
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Mobile Intracardiac Mass after Inguinal Hernia Repair: An Unresolved Treatment Dilemma. Case Rep Cardiol 2015; 2015:375089. [PMID: 26351587 PMCID: PMC4553172 DOI: 10.1155/2015/375089] [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: 03/09/2015] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 11/17/2022] Open
Abstract
Right heart thrombi (RHT) are rare but well-described entity in literature. Their isolation has been considered as confirmatory for the diagnosis of venous thromboembolism (VTE). Even though their isolation aids the diagnosis, physicians are faced with a difficult management dilemma giving the paucity of data to support any treatment decision. We present a case of RHT in an 81-year-old man who presented to hospital with a large mobile right heart thrombus in transit seen on transthoracic echocardiogram (TTE). He was successfully treated with anticoagulation alone. This case highlights the importance of TTE in establishing the diagnosis and describes the interplay of factors influencing treatment decision.
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29
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Shum D, Gore NM. Saddle pulmonary embolus. J Osteopath Med 2015; 115:345. [PMID: 25938533 DOI: 10.7556/jaoa.2015.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Treatment of Submassive Pulmonary Embolism: Knowing When to be Aggressive and When to be Conservative. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:385. [DOI: 10.1007/s11936-015-0385-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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31
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Chen HY. Saddle pulmonary emboli mimicking pulmonary artery dissection. Am J Emerg Med 2015; 33:127.e1-3. [DOI: 10.1016/j.ajem.2014.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/08/2014] [Accepted: 06/09/2014] [Indexed: 11/30/2022] Open
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Pathak R, Giri S, Karmacharya P, Aryal MR, Donato AA. Comparison between saddle versus non-saddle pulmonary embolism: insights from nationwide inpatient sample. Int J Cardiol 2014; 180:58-9. [PMID: 25438212 DOI: 10.1016/j.ijcard.2014.11.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 11/23/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Ranjan Pathak
- Department of Medicine, Reading Health System, West Reading, PA, United States.
| | - Smith Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Paras Karmacharya
- Department of Medicine, Reading Health System, West Reading, PA, United States
| | - Madan Raj Aryal
- Department of Medicine, Reading Health System, West Reading, PA, United States
| | - Anthony A Donato
- Department of Medicine, Reading Health System, West Reading, PA, United States
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Choi KJ, Cha SI, Shin KM, Lim JK, Yoo SS, Lee J, Lee SY, Kim CH, Park JY, Lee WK. Central emboli rather than saddle emboli predict adverse outcomes in patients with acute pulmonary embolism. Thromb Res 2014; 134:991-6. [DOI: 10.1016/j.thromres.2014.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/19/2014] [Accepted: 08/26/2014] [Indexed: 11/13/2022]
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Deepanjali S, Swaminathan RP, Bammigatti C, Arunkumar S, Balamurugan N, Karthikeyan B, Ramesh A. Saddle pulmonary thromboembolism. QJM 2014; 107:581-2. [PMID: 24222701 DOI: 10.1093/qjmed/hct226] [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] [Indexed: 11/14/2022] Open
Affiliation(s)
- Surendran Deepanjali
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Rathinam P Swaminathan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Subbiah Arunkumar
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Nathan Balamurugan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Balasubramanian Karthikeyan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Ananthakrishnan Ramesh
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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Vedovati MC, Germini F, Agnelli G, Becattini C. Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta-analysis. J Thromb Haemost 2013; 11:2092-102. [PMID: 24134450 DOI: 10.1111/jth.12429] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with acute pulmonary embolism (PE), risk stratification is indicated for tailoring of both diagnostic strategies and acute treatment. Whether embolic burden assessed at computed tomography (CT) angiography has a role in risk stratification in these patients is debated. OBJECTIVE To systematically review and perform a meta-analysis to evaluate the role of CT-assessed burden associated with embolic obstruction and embolic localization in the prognostic stratification of patients with acute PE. METHODS We performed a systematic search in EMBASE and MEDLINE up until 30 June 2013. Studies reporting on the 30-day outcome of patients with confirmed PE and CT-assessed embolic burden were included. The study outcome was death. RESULTS Thirty studies reporting on the prognostic value of CT-assessed embolic burden met the inclusion criteria for this systematic review; of these, 19 were included in the meta-analysis. Five studies (2215 patients) were included in the analysis of localization: an association between embolus localization in the central arteries and 30-day mortality was found after heterogeneity was resolved (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.29-3.89, I(2) = 0%). No correlation was observed between obstruction index (according to the Qanadli scoring system) and 30-day mortality after heterogeneity was reduced (16 studies, 3884 patients, OR 1.22, 95% CI 0.99-1.51, I(2) = 27%). CONCLUSION Localization of emboli assessed at CT angiography can be used for risk stratification in patients with acute PE. Moreover, no correlation was observed between obstruction index and prognosis.
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Affiliation(s)
- M C Vedovati
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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36
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Kwak MK, Kim WY, Lee CW, Seo DW, Sohn CH, Ahn S, Lim KS, Donnino MW. The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism. Br J Radiol 2013; 86:20130273. [PMID: 24058095 PMCID: PMC3856545 DOI: 10.1259/bjr.20130273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/22/2013] [Accepted: 09/17/2013] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE. METHODS In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined. RESULTS Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01). CONCLUSION At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE. ADVANCES IN KNOWLEDGE The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE.
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Affiliation(s)
- M K Kwak
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Yagmur J, Atas H, Cansel M, Akturk E, Yetkin O. Saddle Pulmonary Embolism Visualized by Real Time Three-Dimensional Echocardiography. Echocardiography 2012; 29:E8-9. [DOI: 10.1111/j.1540-8175.2011.01539.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
BACKGROUND Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients. OBJECTIVE To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%). CONCLUSIONS Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.
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Size does matter (not)*. Crit Care Med 2011; 39:2560-1. [DOI: 10.1097/ccm.0b013e31822a582b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gandara E, Bose G, Erkens P, Rodgers M, Carrier M, Wells P. Outcomes of saddle pulmonary embolism: a nested case-control study. J Thromb Haemost 2011; 9:867-9. [PMID: 21232009 DOI: 10.1111/j.1538-7836.2011.04189.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Daher IN, Bathina JD, Bukhari FJ, Yusuf SW. Saddle pulmonary embolism with normal right ventricular function: a treatment enigma. JRSM SHORT REPORTS 2010; 1:12. [PMID: 21103104 PMCID: PMC2984336 DOI: 10.1258/shorts.2009.090357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | | | | | - Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1451, Houston, Texas 77030, USA
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Musani MH. Asymptomatic Saddle Pulmonary Embolism: Case Report and Literature Review. Clin Appl Thromb Hemost 2010; 17:337-9. [DOI: 10.1177/1076029610363588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Saddle pulmonary embolism is defined as a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Patient with saddle pulmonary embolism have a 2-week mortality of 5.8%. 46 years old, hypertensive male, presented with right leg swelling and pain, with no evidence of cardiopulmonary distress. CTA showed a large saddle pulmonary embolus. Doppler ultrasound of right lower extremity, revealed a large filling defect extending from the common femoral vein distally involving the deep femoral vein, femoral vein and popliteal vein on the right. Diagnosis of saddle embolus on its own is not associated with an unfavorable outcome, therefore should not influence management of PE. Echocardiography done within 48hours in-patient with symptomatic saddle pulmonary embolism reveals mild to moderate right ventricular enlargement in 90% and mild to severe right ventricular dysfunction in 80%. Emerging evidence suggest that primary therapy with thrombolytics and embolectomy, should be used in PE patients who presents with hypotension plus moderate to severe right ventricular dysfunction on echo cardiogram. Patients with saddle pulmonary embolism can have normal cardiopulmonary reserve; these patients can be managed with conventional treatment for pulmonary embolism in hospital settings, in order to deal with any complications developed during management. Aggressive management should be reserved for patients who are hemodynamically unstable as well as those with echocardiographic evidence of severe right ventricular strain. Physicians should decrease their threshold for suspicion of pulmonary embolism in patients with deep venous thrombosis in the hope of revealing more and more hidden cases of pulmonary embolism.
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Affiliation(s)
- Muzammil H. Musani
- Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, MI, USA,
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Yusuf SW, Gladish G, Lenihan DJ, Lei X, Durand JB, Swafford J, Daher IN. Computerized tomographic finding of saddle pulmonary embolism is associated with high mortality in cancer patients. Intern Med J 2009; 40:293-9. [DOI: 10.1111/j.1445-5994.2009.01914.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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