1
|
Baron E, Szymanski C, Hergault H, Lepère C, Dubourg O, Hauguel-Moreau M, Mansencal N. Progression of Carcinoid Heart Disease in the Modern Management Era. J Am Heart Assoc 2021; 10:e020475. [PMID: 34816734 PMCID: PMC9075379 DOI: 10.1161/jaha.120.020475] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The development of carcinoid heart disease (CaHD) is still relatively unclear. It is difficult to define an optimal follow‐up for patients without any cardiac involvement at baseline. The aim of this study was to assess the prevalence and natural history of CaHD by annual echocardiographic examinations. Methods and Results We studied 137 consecutive patients (61±12 years, 53% men) with proven digestive endocrine tumor and carcinoid syndrome between 1997 and 2017. All patients underwent serial conventional transthoracic echocardiographic studies. Right‐sided and left‐sided CaHD were systematically assessed. We used a previous validated echocardiographic scoring system of severity for the assessment of CaHD. An increase of 25% of the score was considered to be significant. Mean follow‐up was 54±45 months. Prevalence of CaHD was 27% at baseline and 32% at 5‐year follow‐up. Disease progression was reported in 28% of patients with initial CaHD followed up for >2 years (n=25). In patients without any cardiac involvement at baseline, occurrence of disease was 21%. CaHD occurred >5 years from the initial echocardiographic examination in 42% of our cases, especially in patients presenting with new recurrence of a digestive endocrine tumor. An increase of urinary 5‐hydroxyindoleacetic acid by 25% during follow‐up was identified as an independent predictor of CaHD occurrence during follow‐up (hazard ratio [HR], 5.81; 95% CI, 1.19–28.38; P=0.03), as well as a maximum value of urinary 5‐hydroxyindoleacetic acid >205 mg/24 h during follow‐up (HR, 8.41; 95% CI, 1.64–43.07; P=0.01). Conclusions Our study demonstrates that in patients without initial CaHD, cardiac involvement may occur late and is related to serotonin. Our data emphasize the need for cardiologic follow‐up in patients with recurrence of the tumor process.
Collapse
Affiliation(s)
- Emilie Baron
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France
| | - Catherine Szymanski
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France.,INSERM U-1018CESPTeam 5 (EpReC, Renal and Cardiovascular Epidemiology)UVSQ Villejuif France
| | - Hélène Hergault
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France
| | - Céline Lepère
- Department of Gastroenterology and Digestive Oncology European Georges Pompidou HospitalAP-HP Paris France
| | - Olivier Dubourg
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France.,INSERM U-1018CESPTeam 5 (EpReC, Renal and Cardiovascular Epidemiology)UVSQ Villejuif France
| | - Marie Hauguel-Moreau
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France.,INSERM U-1018CESPTeam 5 (EpReC, Renal and Cardiovascular Epidemiology)UVSQ Villejuif France
| | - Nicolas Mansencal
- Department of Cardiology Ambroise Paré HospitalAssistance Publique-Hôpitaux de Paris (AP-HP)Centre de référence des cardiomyopathies et des troubles du rythme cardiaque héréditaires ou raresUniversité de Versailles-Saint Quentin (UVSQ) Boulogne France.,INSERM U-1018CESPTeam 5 (EpReC, Renal and Cardiovascular Epidemiology)UVSQ Villejuif France
| |
Collapse
|
2
|
Vieillard-Baron A, Prigent A, Repessé X, Goudelin M, Prat G, Evrard B, Charron C, Vignon P, Geri G. Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:630. [PMID: 33131508 PMCID: PMC7603714 DOI: 10.1186/s13054-020-03345-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
Objective Incidence of right ventricular (RV) failure in septic shock patients is not well known, and tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. Design Ancillary study of the HEMOPRED prospective multicenter study includes patients under mechanical ventilation with circulatory failure. Setting This is a multicenter intensive care unit study Patients Two hundred and eighty-two patients with septic shock were analyzed. Patients were classified in three groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. Interventions None. Measurements and main results In total, 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had a normal TAPSE. Conclusions RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.
Collapse
Affiliation(s)
- Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France. .,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France. .,Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Faculty of Paris Saclay, Villejuif, France.
| | - Amélie Prigent
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France.,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France
| | - Xavier Repessé
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Marine Goudelin
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Gwenaël Prat
- Intensive Care Unit, Brest University Hospital, Brest, France
| | - Bruno Evrard
- Intensive Care Unit, Limoges University Hospital, Limoges, France
| | - Cyril Charron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Philippe Vignon
- Intensive Care Unit, Limoges University Hospital, Limoges, France.,INSERM CIC 1435, Limoges University Hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
| | - Guillaume Geri
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France.,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France.,Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Faculty of Paris Saclay, Villejuif, France
| |
Collapse
|
3
|
Martinez M, Duchenne J, Bobbia X, Brunet S, Fournier P, Miroux P, Perrier C, Pès P, Chauvin A, Claret PG. Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.
Collapse
|
4
|
Myers SJ, Kelly TE, Stowell JR. Successful Point-Of-Care Ultrasound-Guided Treatment of Submassive Pulmonary Embolism. Clin Pract Cases Emerg Med 2018; 1:340-344. [PMID: 29849348 PMCID: PMC5965210 DOI: 10.5811/cpcem.2017.7.34504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/01/2017] [Accepted: 07/28/2017] [Indexed: 11/11/2022] Open
Abstract
Pulmonary embolism is associated with significant mortality and impaired long-term functional outcomes. Timely identification and treatment is crucial for successful management. Unfortunately, prompt diagnosis can be challenging in patients without overt signs of cardiovascular compromise. Point-of-care cardiac ultrasound (POCCUS) can be used to identify signs of acute pulmonary embolism, risk stratify patients for adverse outcomes and assess response to therapy. This report describes a patient with submassive pulmonary embolism and evidence of acute right ventricular strain on POCCUS successfully treated with thrombolytic therapy. The dynamic changes observed on point-of-care ultrasound are presented.
Collapse
Affiliation(s)
- Samantha J Myers
- Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona
| | - Thomas E Kelly
- Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona
| | - Jeffrey R Stowell
- Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona
| |
Collapse
|
5
|
Köse A, Karaca MK, Celik A, Biricik S, Ozeren M. Acute pulmonary thromboemboli due to a giant mobile thrombus. Clin Exp Emerg Med 2017; 4:117-118. [PMID: 28717783 PMCID: PMC5511961 DOI: 10.15441/ceem.16.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/07/2017] [Accepted: 02/14/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ataman Köse
- Department of Emergency Medicine, Mersin University School of Medicine, Mersin, Turkey
| | - Mehmet Kerem Karaca
- Department of Cardiovascular Surgery, Mersin University School of Medicine, Mersin, Turkey
| | - Ahmet Celik
- Department of Cardiology, Mersin University School of Medicine, Mersin, Turkey
| | - Serdar Biricik
- Department of Emergency Medicine, Mersin University School of Medicine, Mersin, Turkey
| | - Murat Ozeren
- Department of Cardiovascular Surgery, Mersin University School of Medicine, Mersin, Turkey
| |
Collapse
|
6
|
Évaluation hémodynamique par échographie en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0608-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
7
|
Korkmaz O, Yucel H, Zorlu A, Berkan O, Kaya H, Goksel S, Beton O, Yilmaz MB. Elevated gamma glutamyl transferase levels are associated with the location of acute pulmonary embolism. Cross-sectional evaluation in hospital setting. SAO PAULO MED J 2015; 133:488-94. [PMID: 26648276 PMCID: PMC10496562 DOI: 10.1590/1516-3180.2015.00131806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/08/2015] [Accepted: 06/18/2015] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE The location of embolism is associated with clinical findings and disease severity in cases of acute pulmonary embolism. The level of gamma-glutamyl transferase increases under oxidative stress-related conditions. In this study, we investigated whether gamma-glutamyl transferase levels could predict the location of pulmonary embolism. DESIGN AND SETTING Hospital-based cross-sectional study at Cumhuriyet University, Sivas, Turkey. METHODS 120 patients who were diagnosed with acute pulmonary embolism through computed tomography-assisted pulmonary angiography were evaluated. They were divided into two main groups (proximally and distally located), and subsequently into subgroups according to thrombus localization as follows: first group (thrombus in main pulmonary artery; n = 9); second group (thrombus in main pulmonary artery branches; n = 71); third group (thrombus in pulmonary artery segmental branches; n = 34); and fourth group (thrombus in pulmonary artery subsegmental branches; n = 8). RESULTS Gamma-glutamyl transferase levels on admission, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, pulmonary artery systolic pressure and cardiopulmonary resuscitation requirement showed prognostic significance in univariate analysis. The multivariate logistic regression model showed that gamma-glutamyl transferase level on admission (odds ratio, OR = 1.044; 95% confidence interval, CI: 1.011-1.079; P = 0.009) and pulmonary artery systolic pressure (OR = 1.063; 95% CI: 1.005-1.124; P = 0.033) remained independently associated with proximally localized thrombus in pulmonary artery. CONCLUSIONS The findings revealed a significant association between increased existing embolism load in the pulmonary artery and increased serum gamma-glutamyl transferase levels.
Collapse
Affiliation(s)
- Ozge Korkmaz
- MD. Associate Professor, Department of Cardiovascular Surgery, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Hasan Yucel
- MD. Associate Professor, Department of Cardiology, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Ali Zorlu
- MD. Associate Professor, Department of Cardiology, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Ocal Berkan
- MD. Professor and Head of Department of Cardiovascular Surgery, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Hakki Kaya
- MD. Associate Professor, Department of Cardiology, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Sebahattin Goksel
- MD. Associate Professor, Department of Cardiovascular Surgery, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Osman Beton
- MD. Associate Professor, Department of Cardiology, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| | - Mehmet Birhan Yilmaz
- MD. Professor and Head of Department of Cardiology, Cumhuriyet University Medical Faculty, Sivas, Turkey.
| |
Collapse
|
8
|
The Essentials of Bedside Ultrasound for Pulmonary Embolism. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
9
|
Javadrashid R, Mozayan M, Tarzamni MK, Ghaffari MR, Fouladi DF. Spiral computed tomographic pulmonary angiography in patients with acute pulmonary emboli and no pre-existing comorbidity: a prospective prognostic panel study. Eur Radiol 2014; 25:147-54. [DOI: 10.1007/s00330-014-3383-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 06/21/2014] [Accepted: 08/05/2014] [Indexed: 01/22/2023]
|
10
|
Tajbakhsh N, Wu H, Xue W, McMahon EM, Belohlavek M, Liang J. Motion analysis of right ventricular dysfunction under mild or moderate pressure overload caused by acute pulmonary embolism. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:2066-2074. [PMID: 23969162 DOI: 10.1016/j.ultrasmedbio.2013.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 05/18/2013] [Accepted: 05/22/2013] [Indexed: 06/02/2023]
Abstract
Acute pulmonary embolism (APE) is the third most common cause of death in the United States. Appearing as a sudden blockage in a major pulmonary artery, APE may cause mild, moderate or severe right ventricular (RV) overload. Although severe RV overload produces diagnostically obvious RV mechanical failure, little progress has been made in gaining a clinical and biophysical understanding of moderate and mild acute RV overload and its impact on RV functionality. In the research described here, we conducted a pilot study in pigs using echocardiography and observed the following abnormalities in RV functionality under acute mild or moderate RV overload: (i) occurrence of paradoxical septal motion with "waving" dynamics; (ii) decrease in local curvature of the septum (p < 0.01); (iii) lower positive correlation between movement of the RV free wall and movement of the septum (p < 0.05); (iv) slower rate of RV fractional area change (p < 0.05); and (v) decrease in movement stability, particularly in the middle of the septum (p < 0.05).
Collapse
Affiliation(s)
- Nima Tajbakhsh
- Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, USA.
| | | | | | | | | | | |
Collapse
|
11
|
Tong C, Zhang Z. Evaluation factors of pulmonary embolism severity and prognosis. Clin Appl Thromb Hemost 2013; 21:273-84. [PMID: 24023267 DOI: 10.1177/1076029613501540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Management of pulmonary embolism (PE) is still unclear. We summarized 16 kinds of evaluation factors of PE severity and prognosis, and we analyzed the single and joint value for short-term and long-term prognosis. Among them, biomarkers such as brain natriuretic peptide or N-terminal probrain natriuretic peptide, troponin, and heart-type fatty acid-binding protein are the best indicators of PE severity and short-term prognosis. They might replace imaging detections in evaluating PE severity. But the positive predictive value of all the biomarkers is low, and we need to improve each value through joint detection. The PE severity index and simplified PE severity index are more suitable for evaluating the overall risk and long-term prognosis. They could be used as complements of indicators of the PE severity, especially in identifying low-risk group. Integrated risk stratification and strategies of management should be established based on the 2 aspects mentioned previously.
Collapse
Affiliation(s)
- ChunRan Tong
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - ZhongHe Zhang
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| |
Collapse
|
12
|
Red flag in bedside echocardiography for acute pulmonary embolism: remembering McConnell's sign. Am J Emerg Med 2013; 31:719-21. [PMID: 23394891 DOI: 10.1016/j.ajem.2012.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 11/26/2012] [Accepted: 11/27/2012] [Indexed: 11/21/2022] Open
Abstract
Dyspnea is a common symptom among emergency department (ED) patients. The differential diagnosis of dyspnea in ED patients is broad, and pulmonary embolism (PE) is a crucial consideration among these. Recognition of right ventricular (RV) dysfunction is critical in patients with PE. Here, we present a 76-year-old male patient with the complaint of dyspnea. Focused cardiac ultrasonography performed by the emergency physician revealed enlarged RV, hypokinetic lateral wall and hyperkinetic apex of RV (McConnell's sign). We have screened the deep venous system of the patient with the linear probe for possible deep venous thrombosis and showed that the right dilated uncompressible popliteal vein had a thrombus formation. Computed tomography angiography of the thorax revealed filling defects in both main pulmonary arteries. Our case shows that bedside ultrasonography is a valuable tool for detecting PE and decision making in PE patients.
Collapse
|
13
|
Conséquences hémodynamiques de l’embolie pulmonaire. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0449-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
14
|
|
15
|
Hubbard J, Saad WEA, Sabri SS, Turba UC, Angle JF, Park AW, Matsumoto AH. Rheolytic Thrombectomy with or without Adjunctive Indwelling Pharmacolysis in Patients Presenting with Acute Pulmonary Embolism Presenting with Right Heart Strain and/or Pulseless Electrical Activity. THROMBOSIS 2011; 2011:246410. [PMID: 22254138 PMCID: PMC3255315 DOI: 10.1155/2011/246410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 07/20/2011] [Indexed: 12/13/2022]
Abstract
Purpose. To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA). Materials and Methods. Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004-06/2009). Pre- and posttreatment Miller index scoring weres calculated and compared. Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis. Results. 11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16-27, mean: 23.2). CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients. 3 (27%) patients presented with a PEA event. Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone. The intraprocedural mortality was 9% (n = 1/11). Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy. Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis. The mean catheter-directed infusion duration was 18 hours (range of 12-26 hours). The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively. There was a 91% (10/11) technical success rate. The failure was the single mortality. Average reduction in Miller score was 9.5 or 41% (P = 0.009), obstructive index of 6.4 or 47% (P = 0.03), and perfusion index of 2.7 or 28% (P = 0.05). Average ICU and hospital stay were 7.4 days (range 2-27 days) and 21.3 days (range 6-60 days), respectively. Intent to treat survival was 90% at 6, 12, and 18 months. Conclusion. Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.
Collapse
Affiliation(s)
- J. Hubbard
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - W. E. A. Saad
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - S. S. Sabri
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - U. C. Turba
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - J. F. Angle
- Division of Interventional Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - A. W. Park
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - A. H. Matsumoto
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| |
Collapse
|
16
|
CT Imaging of Pulmonary Embolism: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9112-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
17
|
Planquette B, Belmont L, Meyer G, Sanchez O. [Update on diagnosis and treatment of high-risk pulmonary embolism]. Rev Mal Respir 2011; 28:778-89. [PMID: 21742239 DOI: 10.1016/j.rmr.2010.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 11/10/2010] [Indexed: 11/27/2022]
Abstract
INTRODUCTION High-risk pulmonary embolism (PE) is associated with a significant early mortality, approaching 25%, and is defined by the presence of cardiogenic shock. STATE OF THE ART The high early mortality rate for patients with shock requires a rapid diagnostic approach with bedside tests. Right ventricular dilatation assessed by echocardiography in patients with a high clinical probability for PE confirms the diagnosis without the need for additional testing. Spiral CT pulmonary angiography remains the first line investigation for patients without shock. Anticoagulant treatment should be started as soon as pulmonary embolism is suspected. Fibrinolytic therapy is recommended for patients with high-risk pulmonary embolism. The prognostic value of cardiac biomarkers, such as B natriuretic peptide, troponins and right ventricular dilatation for early mortality has been demonstrated. These markers permit the identification of an intermediate risk group of patients with normotensive pulmonary embolism and prognostic scores have been developed. PERSPECTIVES It remains to be established whether fibrinolysis can have a clinical benefit or reduce mortality in patients with intermediate risk pulmonary embolism. A large randomised placebo-controlled study is currently under way to answer this question. Further studies will more clearly define the role of various predictive rules to identify patients requiring hospital care or those who should be considered for outpatient management.
Collapse
Affiliation(s)
- B Planquette
- Université Paris-Descartes, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France.
| | | | | | | |
Collapse
|
18
|
Golpe R, Pérez-de-Llano LA, Castro-Añón O, Vázquez-Caruncho M, González-Juanatey C, Veres-Racamonde A, Iglesias-Moreira C, Fariñas MC. Right ventricle dysfunction and pulmonary hypertension in hemodynamically stable pulmonary embolism. Respir Med 2010; 104:1370-6. [DOI: 10.1016/j.rmed.2010.03.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 03/29/2010] [Accepted: 03/30/2010] [Indexed: 11/28/2022]
|
19
|
Computed tomography for the detection of free-floating thrombi in the right heart in acute pulmonary embolism. Eur Radiol 2010; 21:240-5. [DOI: 10.1007/s00330-010-1942-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 06/27/2010] [Accepted: 07/14/2010] [Indexed: 10/19/2022]
|
20
|
Renard A, Valla A, Sedat J, Ichai C, Quintard H. [Serious pulmonary embolism and thromboaspiration]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:391-394. [PMID: 20409673 DOI: 10.1016/j.annfar.2010.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Accepted: 03/03/2010] [Indexed: 05/29/2023]
Abstract
Pulmonary embolism is a common disease with a mortality rate of approximately 3%. Polytraumatised patients are particularly susceptible to thromboembolism because of prolonged immobilisation and inflammatory syndrome, thrombembolic risk also increases significantly during the peripartum period. Rapid diagnosis and intervention are essential for survival. Conventional treatment consists of systemic intravascular thrombolysis, but this procedure is often contraindicated in intensive care patients because of the high risk of haemorrhage. We report two cases of successful treatment using radiological endovascular thrombectomy.
Collapse
Affiliation(s)
- A Renard
- Réanimation médicochirurgicale, hôpital St-Roch, CHU de Nice, université Nice Sophia-Antipolis, 4, rue Pierre-Dévoluy, 06006 Nice, France
| | | | | | | | | |
Collapse
|
21
|
Henzler T, Krissak R, Reichert M, Sueselbeck T, Schoenberg SO, Fink C. Volumetric analysis of pulmonary CTA for the assessment of right ventricular dysfunction in patients with acute pulmonary embolism. Acad Radiol 2010; 17:309-15. [PMID: 20152725 DOI: 10.1016/j.acra.2009.10.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 10/21/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
Abstract
RATIONALE AND OBJECTIVES To retrospectively determine the value of a volumetric ventricle analysis for the assessment of right ventricular dysfunction in patients with suspected pulmonary embolism (PE) by using image data from non-electrocardiographically (ECG)-gated multidetector computed tomography angiography (CTA). MATERIALS AND METHODS Hypothesizing that the presence of PE and the embolus location correlated with right ventricular dysfunction, we retrospectively analyzed 100 non-ECG-gated pulmonary CTA datasets of patients with central, peripheral, and without PE. Right ventricle/left ventricle (RV/LV) diameter ratio measured in transverse sections (RV/LV(trans)), four-chamber view (RV/LV(4ch)), and RV/LV volume ratio (RV/LV(vol)) were assessed on CT images. The results were correlated with the embolus location, the 30-day mortality rate, and the necessity of intensive care treatment. RESULTS All CT parameters showed statistically significant differences between all patients groups depended on embolus location. The receiver operating characteristic analysis RV/LV(vol) showed the strongest discriminatory power to differ between patients with central and without PE and between patients with central and peripheral PE (central PE vs. no PE: RV/LV(vol) = 0.932, RV/LV(trans) = 0.880, and RV/LV(4ch) = 0.811, central PE vs. peripheral PE: RV/LV(vol) = 0.950, RV/LV(trans) = 0.849, and RV/LV(4ch) = 0.881), indicating a correlation with embolus location predisposing for RVD. For the identification of high-risk patients with PE all three CT parameters showed statistically significant values (P < .0001), whereas in the receiver operating characteristic analysis, RV/LV(vol) had the strongest discriminatory power (RV/LV(vol) = 0.819, RV/LV(trans) = 0.799, and RV/LV(4ch) = 0.758). CONCLUSION Ventricle volumetry of non-ECG-gated CTA allows the assessment of right ventricular dysfunction in patients with acute PE. Compared to unidimensional measurements, a volumetric analysis seems to be slightly superior to identify high-risk patients with adverse clinical outcome. However, the method is more time consuming and requires dedicated software tools compared to unidimensional parameters, which is disadvantageous in an emergency setting.
Collapse
|
22
|
Pharmacological Support of the Failing Right Ventricle. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
23
|
Kjaergaard J, Schaadt BK, Lund JO, Hassager C. Prognostic importance of quantitative echocardiographic evaluation in patients suspected of first non-massive pulmonary embolism. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:89-95. [DOI: 10.1093/ejechocard/jen169] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
24
|
Zhu L, Yang Y, Wu Y, Zhai Z, Wang C. Value of right ventricular dysfunction for prognosis in pulmonary embolism. Int J Cardiol 2008; 127:40-5. [PMID: 17716753 DOI: 10.1016/j.ijcard.2007.06.093] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 06/24/2007] [Accepted: 06/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) patients with right ventricular dysfunction (RVD) have a worse prognosis. We assessed RVD, deciding the indexes correlating best with prognosis. METHODS The prospective multi-center study included 520 consecutive APE patients from 41 collaborating hospitals in China, between June 2002 and November 2004. RVD was diagnosed in the presence of at least 2 of the following: right ventricular (RV) dilatation, loss of inspiratory collapse of inferior vena cava (IVC), right ventricular hypokinesis, tricuspid regurgitant jet velocity >2.8 m/s. RESULTS Mean age was 57.4+/-14.1 years and 323 patients (62.1%) were male. The 14-day mortality in normotensive patients with RVD was higher (2.0% vs 0.4%, p<0.01) than without RVD. RVD was associated with adverse 14-day outcomes (OR 5.23, 95% CI, 2.44-11.23) and the combination of RV dilation and IVC broadening was more valuable than the combination of RV dilation and RV hypokinesis (p<0.01). A multiple logistic regression model implied that RVD, right/left ventricular end-diastolic diameter ratio (RVED/LVED) and systolic pulmonary artery pressure (SPAP) be independent predictors of adverse 14-day clinical outcomes (p<0.01). ROC curve showed that the best cut-off values of RVED/LVED and SPAP were 0.67 and 60 mm Hg, respectively. Hemodynamic instability, 14-day clinical outcome, and SPAP were independent harbingers for 3-month outcomes (p<0.01). CONCLUSIONS RVD was a discriminator for a poor prognosis in normotensive patients. Early detection of RVD (especially combination of RV dilation and IVC broadening, RVED/LVED>0.67 and/or SPAP>60 mm Hg) was beneficial for identifying high-risk patients. Hemodynamic instability, 14-day clinical outcomes, and SPAP independently predicted 3-month clinical outcomes.
Collapse
Affiliation(s)
- Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China
| | | | | | | | | |
Collapse
|
25
|
Stawicki SP, Seamon MJ, Meredith DM, Chovanes J, Paszczuk A, Kim PK, Gracias VH. Transthoracic echocardiography for suspected pulmonary embolism in the intensive care unit: unjustly underused or rightfully ignored? JOURNAL OF CLINICAL ULTRASOUND : JCU 2008; 36:291-302. [PMID: 18361466 DOI: 10.1002/jcu.20461] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.
Collapse
Affiliation(s)
- S Peter Stawicki
- Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 2 Dulles, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Mansencal N, Vieillard-Baron A, Beauchet A, Farcot JC, El Hajjam M, Dufaitre G, Brun-Ney D, Lacombe P, Jardin F, Dubourg O. Triage Patients with Suspected Pulmonary Embolism in the Emergency Department Using a Portable Ultrasound Device. Echocardiography 2008; 25:451-6. [DOI: 10.1111/j.1540-8175.2007.00623.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
27
|
Zhu L, Wang C, Yang Y, Wu Y, Zhai Z, Dai H, Pang B, Tong Z. Value of transthoracic echocardiography in therapy regimens evaluation in pulmonary embolism. J Thromb Thrombolysis 2007; 26:251-6. [PMID: 17705052 DOI: 10.1007/s11239-007-0087-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 08/02/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) causes right ventricular dysfunction (RVD). APE patients with and without RVD can benefit from thrombolytic therapy or anticoagulants. In this study, we assessed the changes of right ventricular (RV) function on transthoracic echocardiography (TTE) after different therapy strategies among a broad spectrum of APE. METHODS The present prospective randomized trial included 520 APE patients from 41 hospitals in China between June 2002 and November 2004. Patients were divided into two groups at presentation: group I (major APE)--52 patients with hemodynamic instability and 198 normotensive patients with RVD; group II (minor APE)--270 normotensive patients without RVD. The patients in group I were randomly divided into four subgroups according to different thrombolytic regimens: A--urokinase 12 h subgroup; B--urokinase 2 h subgroup; C--recombinant tissue-type plasminogen activator (rtPA) 50 mg subgroup and D--rtPA 100 mg subgroup; Different anticoagulants were randomly assigned to patients in group II: NA--heparin subgroup; NB--nadroparin subgroup. TTE were performed before the therapy, and 24 h, 14 days and 3 months after the therapy, respectively. RESULTS Mean age was 57.4 +/- 14.1 years and 323 patients (62.1%) were male. The indexes of RV function on TTE in group I were significantly improved compared with those in group II at each point (P < 0.05) and SPAP decreased after anticoagulants administration in group II. However, there was no difference among thrombolytic subgroups in group I and between the two anticoagulants subgroups in group II. The presence of RVD was much lower (34.0% vs. 100%, P < 0.001) 24 h after thrombolytic therapies than that before the therapy in group I, which documented that thrombolytic agents early reversed RVD in major APE patients. Even 3 months after the therapy, TRPG and SPAP were still higher in group I than those in group II. CONCLUSIONS TTE documented the identical effect of thrombolytic regimen of urokinase 12 h, urokinase 2 h, rtPA 50 mg and rtPA 100 mg in major APE which suggest rtPA 100 mg can supersede rtPA 50 mg in these patients. Heparin produced the similar results compared with nadroparin in minor APE. TTE can monitor the effect DC3 NAK of thrombolysis early and identify the patients with persistent pulmonary hypertension which possibly develop chronic thromboembolic pulmonary hypertension. Therefore, it can facilitate the management of APE.
Collapse
Affiliation(s)
- Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
Multidetector-row computed tomographic (CT) angiography of pulmonary arteries is the first-line imaging technique in patients suspected of having pulmonary embolism (PE). Patient risk stratification is important because optimal management, monitoring, and therapeutic strategies depend on the patient's prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe PE. Acute right-sided heart failure can be assessed on CT pulmonary angiography by measuring the dimensions of the right-sided heart cavities or systemic veins. The magnitude of PE can be calculated on CT pulmonary angiography by applying dedicated CT scores or angiographic scores adapted. This article reviews and discusses the various CT-based methods for risk stratification of patients with acute PE.
Collapse
Affiliation(s)
- C Engelke
- Institut für Röntgendiagnostik, Klinikum der Bayerischen Julius-Maximilians-Universität Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
| | | |
Collapse
|
29
|
Chung T, Kelleher S, Liu PY, Conway AJ, Kritharides L, Handelsman DJ. Effects of testosterone and nandrolone on cardiac function: a randomized, placebo-controlled study. Clin Endocrinol (Oxf) 2007; 66:235-45. [PMID: 17223994 DOI: 10.1111/j.1365-2265.2006.02715.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Androgens have striking effects on skeletal muscle, but the effects on human cardiac muscle function are not well defined, neither has the role of metabolic activation (aromatization, 5alpha reduction) of testosterone on cardiac muscle been directly studied. OBJECTIVE To assess the effects of testosterone and nandrolone, a non-amplifiable and non-aromatizable pure androgen, on cardiac muscle function in healthy young men. DESIGN Double-blind, randomized, placebo-controlled, three-arm parallel group clinical trial. SETTING Ambulatory care research centre. PARTICIPANTS Healthy young men randomized into three groups of 10 men. INTERVENTION Weekly intramuscular injections of testosterone (200 mg mixed esters), nandrolone (200 mg nandrolone decanoate) or matching (2 ml arachis oil vehicle) placebo for 4 weeks. MAIN OUTCOME MEASURES Comprehensive measures of cardiac muscle function involving transthoracic cardiac echocardiography measuring myocardial tissue velocity, peak systolic strain and strain rates, and bioimpedance measurement of cardiac output and systematic vascular resistance. RESULTS Left ventricular (LV) function (LV ejection fraction, LV modified TEI index), right ventricular (RV) function (ejection area, tricuspid annular systolic planar motion, RV modified TEI index) as well as cardiac afterload (mean arterial pressure, systemic vascular resistance) and overall cardiac contractility (stroke volume, cardiac output) were within age- and gender-specific reference ranges and were not significantly (P < 0.05) altered by either androgen or placebo over 4 weeks of treatment. Minor changes remaining within normal range were observed solely within the testosterone group for: increased LV end-systolic diameter (30 +/- 7 vs. 33 +/- 5 mm, P = 0.04) and RV end-systolic area (12.8 +/- 1.3 vs. 14.6 +/- 3.3 cm(2), P = 0.04), reduced LV diastolic septal velocity (Em, 9.5 +/- 2.6 vs. 8.7 +/- 2.0 cm/s, P = 0.006), increased LV filling pressure (E/Em ratio, 7.1 +/- 1.6 vs. 8.3 +/- 1.8, P = 0.02) and shortened PR interval on the electrocardiogram (167 +/- 13 vs. 154 +/- 12, P = 0.03). CONCLUSION Four weeks of treatment with testosterone or nandrolone had no beneficial or adverse effects compared with placebo on cardiac function in healthy young men.
Collapse
Affiliation(s)
- T Chung
- Department of Cardiology, Concord Hospital and ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
| | | | | | | | | | | |
Collapse
|
30
|
Doğan H, Kroft LJM, Huisman MV, van der Geest RJ, de Roos A. Right Ventricular Function in Patients with Acute Pulmonary Embolism: Analysis with Electrocardiography-synchronized Multi–Detector Row CT. Radiology 2007; 242:78-84. [PMID: 17090717 DOI: 10.1148/radiol.2421052089] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively assess electrocardiography (ECG)-synchronized multi-detector row computed tomography (CT) for the evaluation of right ventricular (RV) function in patients suspected of having pulmonary embolism (PE). MATERIALS AND METHODS All patients gave informed consent after the study details, including radiation exposure, were explained; institutional ethical committee approval was obtained. Nonsynchronized multi-detector row CT of the chest was performed in 66 consecutive patients (29 men, 37 women; mean age, 58 years+/-15 [standard deviation]) who were suspected of having PE. ECG-synchronized cardiac multi-detector row CT was performed to assess cardiac function. Dimension ratios for the RV and left ventricle (LV) were measured on nonsynchronized transverse and angulated four-chamber views. Furthermore, the RV end-diastolic and end-systolic volumes were measured on ECG-synchronized multi-detector row CT scans. An independent samples t test was performed to compare the mean value of different groups. An analysis of variance post hoc test was performed to investigate whether the values of the variables varied between groups. RESULTS PE was detected in 29 of 66 patients. The location of PE was categorized as central (n=17) or peripheral (n=12). The RV/LV dimension ratio was larger on the four-chamber view (P=.002), and RV end-systolic volume was larger (P=.01) and ejection fraction was lower (P=.01) in patients with PE. The RV end-systolic volumes and RV/LV volume ratios, as assessed by using ECG-synchronized multi-detector row CT, showed significant differences (P<.005) between patients with central PE and those with peripheral PE. However, the RV/LV dimensions on nonsynchronized images revealed no significant differences. CONCLUSION Retrospective ECG-synchronized multi-detector row CT facilitates detection of RV dysfunction, depending on pulmonary embolus location.
Collapse
Affiliation(s)
- Halil Doğan
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, C2-S, 2333 ZA Leiden, the Netherlands
| | | | | | | | | |
Collapse
|
31
|
Mansencal N, Dubourg O. Free-floating thrombus in the right heart and pulmonary embolism. Int J Cardiol 2006; 112:e33-4. [PMID: 16859771 DOI: 10.1016/j.ijcard.2006.02.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 02/24/2006] [Indexed: 11/25/2022]
Abstract
We describe the case of a woman with acute pulmonary embolism and free-floating thrombus in the right heart. The diagnosis was performed using transthoracic echocardiography. The patient received urgent intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. This observation emphasizes the echocardiographic monitoring during thrombolysis in acute pulmonary embolism, allowing to strictly assess cardiac chamber sizes.
Collapse
|
32
|
Mansencal N, El Hajjam M, Vieillard-Baron A, Pelage JP, Lacombe P, Dubourg O. Recurrent pulmonary embolism with non-mobile thrombus in a patient with leiomyosarcoma of the left renal vein. Int J Cardiol 2006; 112:247-8. [PMID: 16239040 DOI: 10.1016/j.ijcard.2005.07.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2005] [Accepted: 07/24/2005] [Indexed: 11/28/2022]
Abstract
We describe the case of a man who suffered recurrent pulmonary embolisms despite well-conducted oral anticoagulant therapy. Echocardiography and helical computed tomography revealed a non-mobile right atrial mass related to a leiomyosarcoma of the left renal vein. The prognosis of such a disease is bad and the patient died at 1-year follow-up. Recurrent pulmonary embolism with well-conducted oral anticoagulant therapy requires further appropriate investigations, because of high suspicion of neoplastic process.
Collapse
|
33
|
Chung T, Emmett L, Khoury V, Lau GT, Elsik M, Foo F, Allman KC, Kritharides L. Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly. J Am Soc Echocardiogr 2006; 19:347-53. [PMID: 16500500 DOI: 10.1016/j.echo.2005.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute pulmonary thromboembolism (PTE) can be associated with right ventricular (RV) dysfunction. The relative importance of individual echocardiographic parameters, including those suggesting interdependence between right and left heart chambers, in predicting thromboembolic burden in elderly patients with acute PTE is unknown. METHODS We retrospectively studied the transthoracic echocardiograms of 63 elderly patients (age 71 +/- 16 years) with acute PTE, and assessed which individual echocardiographic parameters identified more than 30% pulmonary artery obstruction on the basis of quantitative ventilation/perfusion pulmonary scintigraphy. RESULTS RV hypokinesis (visual grade 0-3, P = .02), and the quantitative parameters RV end-systolic area (P = .005) and RV ejection area (P = .01) were associated with more extensive pulmonary artery obstruction. Although right atrial end-systolic area and RV end-diastolic area did not correlate with extent of PTE, the ratio of RV:left ventricular end-diastolic area (P = .003), and ratio of right:left atrial end-systolic area (P = .004), were strongly associated with the extent of pulmonary artery obstruction. These transthoracic echocardiographic parameters were independent of clinical variables such as prior chronic lung disease, congestive cardiac failure, or prior PTE. CONCLUSION RV systolic dysfunction, RV end-systolic dilatation, right:left atrial end-systolic area ratio, and RV:left ventricular end-diastolic area ratio correlate with extent of PTE in the elderly.
Collapse
Affiliation(s)
- Tommy Chung
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Mansencal N, Mitry E, Forissier JF, Martin F, Redheuil A, Lepère C, Farcot JC, Joseph T, Lacombe P, Rougier P, Dubourg O. Assessment of patent foramen ovale in carcinoid heart disease. Am Heart J 2006; 151:1129.e1-6. [PMID: 16644350 DOI: 10.1016/j.ahj.2006.02.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2005] [Accepted: 02/11/2006] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Carcinoid syndrome may involve right carcinoid heart disease (CHD), secondary to the release of vasoactive substances. Left CHD is rare, as the inactivation of serotonin by the lung protects the left heart. We attempted to evaluate the prevalence of CHD and patent foramen ovale (PFO) with serial contrast transthoracic echocardiographic studies and to determine the markers of right and left CHD progression. METHODS Forty-one consecutive patients with proved digestive endocrine tumor and carcinoid syndrome were prospectively enrolled. All patients underwent serial conventional and contrast transthoracic echocardiographic studies. Right and left CHD, PFO, radiological examinations, and biological carcinoid markers were systematically assessed. RESULTS Left CHD was present in 5 patients at baseline and in 13 patients (32%) during follow-up (P = .03). The 13 patients with left CHD also had PFO, and no left CHD occurred without PFO (P < .0001). Right CHD was present in 16 patients (39%) at baseline and in 25 patients (61%) at the end of follow-up (P = .04). The prevalence of right and left CHD was significantly higher in patients with PFO (88% and 76%, respectively; P < .04). A progression of right and left CHD was present, respectively, in 19 and 9 patients but was mainly found in patients with PFO (15 and 9 patients; P < .0001). The main marker of CHD progression was the presence of PFO (odds ratio 44.2, 95% confidence interval 4.4-447.7; P = .001). CONCLUSIONS PFO is a new marker of CHD progression and should be systematically assessed with routine contrast transthoracic echocardiography in patients with carcinoid syndrome to determine patients at high risk of CHD progression.
Collapse
Affiliation(s)
- Nicolas Mansencal
- Department of Cardiology, University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Ghaye B, Ghuysen A, Bruyere PJ, D'Orio V, Dondelinger RF. Can CT pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? What the radiologist needs to know. Radiographics 2006; 26:23-39; discussion 39-40. [PMID: 16418240 DOI: 10.1148/rg.261055062] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Computed tomographic (CT) pulmonary angiography has been established as a first-line diagnostic technique in patients suspected of having pulmonary embolism. Risk stratification is important in patients with pulmonary embolism because optimal management, monitoring, and therapeutic strategies depend on the prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe pulmonary embolism. Acute right-sided heart failure can be assessed at CT pulmonary angiography by measuring the dimensions of right-sided heart cavities or upstream venous structures, such as the superior vena cava or azygos vein. The magnitude of pulmonary embolism can be calculated at CT pulmonary angiography by applying angiographic scores adapted for CT (Miller and Walsh scores) or dedicated CT scores (Qanadli and Mastora scores). The advent of CT pulmonary angiography performed with electrocardiographic gating permits new advances in assessment of acute right-sided heart failure, such as measurement of the ventricular ejection fraction. Although such findings may be useful for assessment of treatment effectiveness, their effect on prognosis in patients with severe pulmonary embolism is debated in the literature.
Collapse
Affiliation(s)
- Benoît Ghaye
- Department of Medical Imaging, University Hospital of Liege, Sart Tilman B35, B-4000 Liege, Belgium.
| | | | | | | | | |
Collapse
|
36
|
Mansencal N, Dubourg O. Transthoracic echocardiography combined with venous ultrasonography as a diagnostic tool in patients with pulmonary embolism. Int J Cardiol 2006; 107:419-20. [PMID: 16503267 DOI: 10.1016/j.ijcard.2005.01.059] [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: 01/24/2005] [Accepted: 01/28/2005] [Indexed: 11/22/2022]
|
37
|
Girard P. Approche diagnostique de la maladie thromboembolique veineuse. Presse Med 2005; 34:1418-26. [PMID: 16301973 DOI: 10.1016/s0755-4982(05)84203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The diagnosis of pulmonary embolism (PE) and deep venous thrombosis (DVT) has long been based on purely clinical grounds. Pulmonary angiography and scintigraphy, as well as venography, reveal the poor diagnostic value of signs and symptoms of PE and DVT, which are now reduced to the role of triggers for these diagnostic tests. The development of simpler, but still imperfect, diagnostic tools (mainly, D-dimer plasma level, venous compression ultrasound, clinical probability of PE or DVT, spiral CT pulmonary angiography) has led to the development of diagnostic strategies, which use combinations of tests, not to provide diagnostic certainty for every patient (presence or absence of clots), but rather to select populations of patients who need treatment and others who can safely remain untreated. Such pragmatic approaches must be validated in appropriate outcome studies. The choice of a diagnostic strategy should depend not only on the strategy's cost-effectiveness in the population under study but also on the local facilities and expertise required for its use.
Collapse
Affiliation(s)
- P Girard
- Département thoracique, Institut mutualiste Montsouris, 42, bd Jourdan, 75014 Paris.
| |
Collapse
|
38
|
Ghuysen A, Ghaye B, Willems V, Lambermont B, Gerard P, Dondelinger RF, D'Orio V. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax 2005; 60:956-61. [PMID: 16131526 PMCID: PMC1747227 DOI: 10.1136/thx.2005.040873] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients with acute pulmonary embolism (APE) present with a broad spectrum of prognoses. Computed tomographic pulmonary angiography (CTPA) has progressively been established as a first line test in the APE diagnostic algorithm, but estimation of short term prognosis by this method remains to be explored. METHODS Eighty two patients admitted with APE were divided into three groups according to their clinical presentation: pulmonary infarction (n = 21), prominent dyspnoea (n = 29), and circulatory failure (n = 32). CTPA studies included assessment of both pulmonary obstruction index and right heart overload. Haemodynamic evaluation was based on systolic aortic blood pressure, heart rate, and systolic pulmonary arterial pressure obtained non-invasively by echocardiography at the time of diagnosis of pulmonary embolism. RESULTS The mortality rate was 0%, 13.8% and 25% in the three groups, respectively. Neither the pulmonary obstruction index nor the pulmonary artery pressure could predict patient outcome. In contrast, a significant correlation with mortality was found using the systolic blood pressure (p<0.001) and heart rate (p<0.05), as well as from imaging parameters including right to left ventricle minor axis ratio (p<0.005), proximal superior vena cava diameter (p<0.001), azygos vein diameter (p<0.001), and presence of contrast regurgitation into the inferior vena cava (p = 0.001). Analysis from logistic regression aimed at testing for mortality prediction revealed true reclassification of 89% using radiological variables. CONCLUSION These results suggest that CTPA quantification of right ventricular strain is an accurate predictor of in-hospital death related to pulmonary embolism.
Collapse
Affiliation(s)
- A Ghuysen
- Emergency Care, Department of Medicine, University Hospital Centre, Liège, Belgium.
| | | | | | | | | | | | | |
Collapse
|
39
|
Mansencal N, Joseph T, Vieillard-Baron A, Langlois S, El Hajjam M, Qanadli SD, Lacombe P, Jardin F, Dubourg O. Diagnosis of right ventricular dysfunction in acute pulmonary embolism using helical computed tomography. Am J Cardiol 2005; 95:1260-3. [PMID: 15878009 DOI: 10.1016/j.amjcard.2005.01.064] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 01/13/2005] [Accepted: 01/13/2005] [Indexed: 10/25/2022]
Abstract
Forty-six consecutive patients with pulmonary embolism (PE) who underwent pulmonary angiography, helical computed tomography (CT), and echocardiography in the investigators' emergency department were studied. It was determined that the CT right ventricular (RV)/left ventricular (LV) end-diastolic area ratio was correlated with PE obstruction and echocardiography. A CT RV/LV area ratio >1 had a sensitivity of 88% and a specificity of 88% in diagnosing significant PE. The present study suggests that helical CT may be used as a triage tool in acute PE for selecting high-risk patients, using calculation of the RV/LV area ratio to detect RV dysfunction.
Collapse
|
40
|
Mansencal N, Redheuil A, Joseph T, Vieillard-Baron A, Jondeau G, Lacombe P, Jardin F, Dubourg O. Use of transthoracic echocardiography combined with venous ultrasonography in patients with pulmonary embolism. Int J Cardiol 2004; 96:59-63. [PMID: 15203262 DOI: 10.1016/j.ijcard.2003.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2003] [Revised: 05/16/2003] [Accepted: 05/24/2003] [Indexed: 11/15/2022]
Abstract
BACKGROUND The diagnosis of pulmonary embolism (PE) remains difficult. Ultrasounds allow for the exploration of the venous system to great extent and for the detection of indirect signs of PE. The aim of this study was to determine the incidence of acute cor pulmonale (ACP) and deep venous thrombosis (DVT) found by ultrasonographic techniques in a population of patients with PE. METHODS One hundred and seventy-three consecutive patients with acute PE (diagnosed either by spiral computed tomography or selective pulmonary angiography) had subsequently both transthoracic echocardiography (TTE) and venous ultrasonography. The diagnostic criterion used for defining ACP by echocardiography was the right to left ventricular end-diastolic area ratio over (or equal to) 0.6 with paradoxical septal wall motion. The diagnosis of DVT rested on vein incompressibility. RESULTS ACP was found in 56% of our patients while 75% were found to have DVT and 89% of the patients had either ACP or DVT or both. All of the patients with proximal PE had ACP and/or DVT. The presence of ACP using echocardiography was significantly different according to the localization of PE (P<0.0001) and the clinical presentation (P=0.0001). The incidence of ACP and/or DVT was significantly different according to the localization of PE (P=0.001). Echocardiography combined with venous ultrasonography had improved the diagnosis value of venous ultrasonography in only 4% of patients with distal PE (P=0.65). CONCLUSION A combined strategy using echocardiography with venous ultrasonography improves significantly the diagnostic value of venous ultrasonography in proximal and lobar PE and fails in distal PE.
Collapse
Affiliation(s)
- Nicolas Mansencal
- Department of Cardiology, AP-HP, Hôpital Ambroise Paré, 9, avenue Charles de Gaulle, 92100 Boulogne Cedex, France.
| | | | | | | | | | | | | | | |
Collapse
|