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Lanza E, Ammirabile A, Francone M. nnU-Net-based deep-learning for pulmonary embolism: detection, clot volume quantification, and severity correlation in the RSPECT dataset. Eur J Radiol 2024; 177:111592. [PMID: 38968751 DOI: 10.1016/j.ejrad.2024.111592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/17/2024] [Accepted: 06/24/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVES CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism, and DL algorithms are being developed to manage the increase in demand. The nnU-Net is a new auto-adaptive DL framework that minimizes manual tuning, making it easier to develop effective algorithms for medical imaging even without specific expertise. This study assesses the performance of a locally developed nnU-Net algorithm on the RSPECT dataset for PE detection, clot volume measurement, and correlation with right ventricle overload. MATERIALS & METHODS User input was limited to segmentation using 3DSlicer. We worked with the RSPECT dataset and trained an algorithm from 205 PE and 340 negatives. The test dataset comprised 6573 exams. Performance was tested against PE characteristics, such as central, non-central, and RV overload. Blood clot volume (BCV) was extracted from each exam. We employed ROC curves and logistic regression for statistical validation. RESULTS Negative studies had a median BCV of 1 μL, which increased to 345 μL in PE-positive cases and 7,378 μL in central PEs. Statistical analysis confirmed a significant BCV correlation with PE presence, central PE, and increased RV/LV ratio (p < 0.0001). The model's AUC for PE detection was 0.865, with an 83 % accuracy at a 55 μL threshold. Central PE detection AUC was 0.937 with 91 % accuracy at 850 μL. The RV overload AUC stood at 0.848 with 79 % accuracy. CONCLUSION The nnU-Net algorithm demonstrated accurate PE detection, particularly for central PE. BCV is an accurate metric for automated severity stratification and case prioritization. CLINICAL RELEVANCE STATEMENT The nnU-Net framework can be utilized to create a dependable DL for detecting PE. It offers a user-friendly approach to those lacking expertise in AI and rapidly extracts the Blood Clot Volume, a metric that can evaluate the PE's severity.
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Affiliation(s)
- Ezio Lanza
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini, 4, Pieve Emanuele MI 20072, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy.
| | - Angela Ammirabile
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini, 4, Pieve Emanuele MI 20072, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Marco Francone
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini, 4, Pieve Emanuele MI 20072, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
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Keskin B, Karagoz A, Hakgor A, Kultursay B, Tanyeri S, Tokgoz HC, Kulahcioglu S, Tosun A, Bulus C, Sekban A, Tanboga IH, Ozdemir N, Kaymaz C. A novel method for the evaluation of right ventricular dysfunction in acute pulmonary embolism: Myocardial work indices. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 38760961 DOI: 10.1002/jcu.23716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/16/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE The presence of right ventricular dysfunction indicates a higher risk status in patients with pulmonary embolism (PE). The RV strain evaluated by speckle-tracking echocardiography seems to be more reliable method in the evaluation of RV dysfunction as compared to standard echocardiographic measures. In this study, we aimed to determine the value of myocardial-work indices in evaluating serial changes of RV function in acute PE. METHODS Our study comprised 83 consecutive acute PE patients who admitted to our tertiary cardiovascular hospital. Echocardiography was performed within the first 24-hours of hospitalization, and RV and LV myocardial-work parameters were obtained along with standard echocardiographic parameters. The change in the RV/LVr detected on tomography was selected as the primary outcome measure, and its' predictors were analyzed with classical linear regression and a generalized additive model (GAM). RESULTS Among the LV-RV strain and myocardial work parameters, the RV global longitudinal strain (GLS) has borderline statistical significance in predicting the RV/LVr change whereas the RV global work efficiency (RV-GWE) strongly predicted RV/LVr change (p: 0.049 and <0.001, respectively). CONCLUSION In this study, classical linear regression and GAM analyses showed that RV-GWE seems to offer a better prediction of RV/LVr change in patients with acute PE.
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Affiliation(s)
- Berhan Keskin
- Department of Cardiology, Kocaeli City Hospital, Kocaeli, Turkey
| | - Ali Karagoz
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | | | - Barkın Kultursay
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Seda Tanyeri
- Department of Cardiology, Kocaeli City Hospital, Kocaeli, Turkey
| | - Hacer Ceren Tokgoz
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Seyhmus Kulahcioglu
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Ayhan Tosun
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Cagdas Bulus
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Ahmet Sekban
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Ibrahim H Tanboga
- Department of Cardiology, Nisantası University, Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Nihal Ozdemir
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
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Lyhne MD, Schultz JG, Mortensen CS, Kramer A, Nielsen-Kudsk JE, Andersen A. Immediate cardiopulmonary responses to consecutive pulmonary embolism: a randomized, controlled, experimental study. BMC Pulm Med 2024; 24:233. [PMID: 38745282 PMCID: PMC11093735 DOI: 10.1186/s12890-024-03006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/10/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (PE) induces ventilation-perfusion mismatch and hypoxia and increases pulmonary pressure and right ventricular (RV) afterload, entailing potentially fatal RV failure within a short timeframe. Cardiopulmonary factors may respond differently to increased clot burden. We aimed to elucidate immediate cardiopulmonary responses during successive PE episodes in a porcine model. METHODS This was a randomized, controlled, blinded study of repeated measurements. Twelve pigs were randomly assigned to receive sham procedures or consecutive PEs every 15 min until doubling of mean pulmonary pressure. Cardiopulmonary assessments were conducted at 1, 2, 5, and 13 min after each PE using pressure-volume loops, invasive pressures, and arterial and mixed venous blood gas analyses. ANOVA and mixed-model statistical analyses were applied. RESULTS Pulmonary pressures increased after the initial PE administration (p < 0.0001), with a higher pulmonary pressure change compared to pressure change observed after the following PEs. Conversely, RV arterial elastance and pulmonary vascular resistance was not increased after the first PE, but after three PEs an increase was observed (p = 0.0103 and p = 0.0015, respectively). RV dilatation occurred following initial PEs, while RV ejection fraction declined after the third PE (p = 0.004). RV coupling exhibited a decreasing trend from the first PE (p = 0.095), despite increased mechanical work (p = 0.003). Ventilatory variables displayed more incremental changes with successive PEs. CONCLUSION In an experimental model of consecutive PE, RV afterload elevation and dysfunction manifested after the third PE, in contrast to pulmonary pressure that increased after the first PE. Ventilatory variables exhibited a more direct association with clot burden.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark.
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, DK-8200, Denmark.
| | - Jacob Gammelgaard Schultz
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Christian Schmidt Mortensen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
| | - Anders Kramer
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Asger Andersen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Yamazoe S, Imai H, Ogawa Y, Kano N, Murase Y, Mamiya K, Ikeda T, Hiramatsu K, Torii J, Kawaguchi K. The effect of off-label use of reduced-dose direct oral anticoagulants therapy in the treatment of pulmonary embolism comparable to standard-dose therapy. Heart Vessels 2024; 39:365-372. [PMID: 38381170 PMCID: PMC10920432 DOI: 10.1007/s00380-023-02339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/08/2023] [Indexed: 02/22/2024]
Abstract
Direct oral anticoagulants (DOACs) have been shown to be effective and safe in preventing pulmonary embolism recurrence. In this single-center retrospective observational study, we aimed to evaluate the efficacy and safety of reduced-dose DOACs in 86 consecutive patients with acute pulmonary embolism. Patients were divided into standard-dose and reduced-dose DOACs groups. Initial clot volume did not significantly differ between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 18.8 [Q1-Q3 7.3-30.8] mL vs. 10.0 [Q1-Q3 3.2-27.9] mL, p = 0.1). Follow-up computed tomography (CT) within 30 days showed a higher rate of clot volume reduction or disappearance in the standard-dose group compared to the reduced-dose group (standard-dose DOACs vs. reduced-dose DOACs, 81.6% vs. 53.9%, p = 0.02). However, at the final follow-up CT, there was no significant difference in clot volume change between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 91.5% vs. 82.0%, p = 0.19). Major bleeding occurred in two patients in the standard-dose group (4.3%) and three patients in the reduced-dose DOACs group (7.7%) (p = 0.5). In conclusion, while standard-dose DOACs demonstrated superior efficacy in early clot reduction, reduced doses of apixaban and edoxaban showed comparable efficacy and safety profiles in long-term treatment of acute pulmonary embolism in certain patients.
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Affiliation(s)
- Shinji Yamazoe
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Hajime Imai
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan.
| | - Yasuhiro Ogawa
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Naoaki Kano
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Yosuke Murase
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Keita Mamiya
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Tomoyo Ikeda
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Kei Hiramatsu
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Jun Torii
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Katsuhiro Kawaguchi
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
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Zeng Y, Liu P, Xie A, Che Y, Yi X, Liu S, Sun W, Liu J, Wang G. Alterations and Significance of Computed Tomography Pulmonary Angiography-Derived Parameters in Older Patients With Acute Pulmonary Embolism. J Comput Assist Tomogr 2024; 48:226-232. [PMID: 37965776 DOI: 10.1097/rct.0000000000001558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVE This study aimed to investigate changes of computed tomography pulmonary angiography (CTPA)-derived parameters in older adults with acute pulmonary embolism (APE). METHODS According to the pulmonary artery obstruction index (PAOI), patients with APE were divided into the A1 (PAOI ≥30%, n = 57) and A2 (PAOI <30%, n = 40) groups. Participants without APE were placed in group B (n = 170). The left atrial (LA) and left ventricular (LV) parameters among the three groups were compared, and the parameter changes in the 44 patients with APE were analyzed before and after treatment. The correlation between APE severity and the parameters was analyzed using correlation analysis. RESULTS The left-to-right diameters (LR) of LA, and LR × anteroposterior diameters (AP) of LA and LV: A1 < A2 < B; LR of LV: A1 < A2, B; AP of LA and LV: A1, A2 < B. After treatment, LR and LR × AP of the LA and LV were significantly increased in the group A1 and LR of the LV and LR × AP of the LA and LV were elevated in the group A2. Acute pulmonary embolism severity was closely associated with LR × AP ( r = -0.557) and LR ( r = -0.477) of LA. CONCLUSIONS With an increase in the degree of obstruction, older adults had a smaller LA and LV. Furthermore, the LR and LR × AP values of the LA were significantly decreased. These results contribute to in-time risk stratification.
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Affiliation(s)
- Yuli Zeng
- From the Department of Radiology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, People's Republic of China
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Fang A, Mayorga-Carlin M, Han P, Cassady S, John T, LaRocco A, Etezadi V, Jones K, Nagarsheth K, Toursavadkohi S, Jeudy J, Anderson D, Griffith B, Sorkin JD, Sarkar R, Lal BK, Cires-Drouet RS. Risk factors and treatment interventions associated with incomplete thrombus resolution and pulmonary hypertension after pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101665. [PMID: 37595746 PMCID: PMC10939011 DOI: 10.1016/j.jvsv.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Residual pulmonary vascular occlusion (RPVO) affects one half of patients after a pulmonary embolism (PE). The relationship between the risk factors and therapeutic interventions for the development of RPVO and chronic thromboembolic pulmonary hypertension is unknown. METHODS This retrospective review included PE patients within a 26-month period who had baseline and follow-up imaging studies (ie, computed tomography [CT], ventilation/perfusion scans, transthoracic echocardiography) available. We collected the incidence of RPVO, percentage of pulmonary artery occlusion (%PAO), baseline CT %PAO, most recent CT %PAO, and difference between the baseline and most recent %PAO on CT (Δ%PAO). RESULTS A total of 354 patients had imaging reports available; 197 with CT and 315 with transthoracic echocardiography. The median follow-up time was 144 days (interquartile range [IQR], 102-186 days). RPVO was present in 38.9% of the 354 patients. The median Δ%PAO was -10.0% (IQR, -32% to -1.2%). Fewer patients with a provoked PE developed RPVO (P ≤ .01), and the initial troponin level was lower in patients who developed RPVO (P = .03). The initial thrombus was larger in the patients who received advanced intervention vs anticoagulation (baseline CT %PAO: median, 61.2%; [IQR, 27.5%-75.0%] vs median, 12.5% [IQR, 2.5%-40.0%]; P ≤ .0001). Catheter-directed thrombolysis (CDT; median Δ%PAO, -47.5%; IQR, -63.7% to -8.7%) and surgical pulmonary embolectomy (SPE; median Δ%PAO, -42.5; IQR, -68.1% to -18.7%) had the largest thrombus reduction compared with anticoagulation (P = .01). Of the 354 patients, 76 developed pulmonary hypertension; however, only 14 received pulmonary hypertension medications and 12 underwent pulmonary thromboendarterectomy. Cancer (odds ratio [OR], 1.7) and planned prolonged anticoagulation (>1 year; OR, 2.20) increased the risk of RPVO. In contrast, the risk was lower for men (OR, 0.61), patients with recent surgery (OR, 0.33), and patients treated with SPE (OR, 0.42). A larger Δ%PAO was found in men (coefficient, -8.94), patients with a lower body mass index (coefficient, -0.66), patients treated with CDT (coefficient, -18.12), and patients treated with SPE (coefficient, -21.69). A lower Δ%PAO was found in African-American patients (coefficient, 7.31). CONCLUSIONS The use of CDT and SPE showed long-term benefit in thrombus reduction.
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Affiliation(s)
- Adam Fang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | - Paul Han
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Cassady
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas John
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Allison LaRocco
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Vahid Etezadi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | | | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Baltimore Veterans Affairs Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, MD
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Bejjani A, Khairani CD, Piazza G. Right Ventricular Recovery: Early and Late Changes after Acute PE Diagnosis. Semin Thromb Hemost 2023; 49:797-808. [PMID: 35777420 DOI: 10.1055/s-0042-1750025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Right ventricular (RV) failure is a critical cause of morbidity and mortality in patients presenting with pulmonary embolism (PE). The presentation of RV failure is based on the combination of clinical findings, laboratory abnormalities, and imaging evidence. An improved understanding of the pathophysiology of RV dysfunction following PE has given rise to more accurate risk stratification and broader therapeutic approaches. A subset of patients with PE develop chronic RV dysfunction with or without pulmonary hypertension. In this review, we focus on the impact of PE on the RV and its implications for risk stratification, prognosis, acute management, and long-term therapy.
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Affiliation(s)
- Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Akhoundi N, Sedghian S, Siami A, Yazdani nia I, Naseri Z, Ghadiri Asli SM, Hazara R. Does Adding the Pulmonary Infarction and Right Ventricle to Left Ventricle Diameter Ratio to the Qanadli Index (A Combined Qanadli Index) More Accurately, Predict Short-Term Mortality in Patients with Pulmonary Embolism? Indian J Radiol Imaging 2023; 33:478-483. [PMID: 37811186 PMCID: PMC10556326 DOI: 10.1055/s-0043-1769590] [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] [Indexed: 10/10/2023] Open
Abstract
Background The Qanadli index can be used to assess the severity of pulmonary arterial involvement in patients with acute pulmonary embolism. However, it seems that considering pulmonary infarction and right ventricle/left ventricle (RV/LV) ratio along with this index (called the combined Qanadli index) can provide a more accurate view of changes in cardiovascular parameters in these patients and help predict mortality in a better manner. In this regard, we evaluated the ability of the combined Qanadli index versus the Qanadli index in predicting short-term mortality in patients with pulmonary embolism. Methods This retrospective study enrolled 234 patients with acute pulmonary embolism. Patients were divided into two groups: those who expired in 30 days and who survived. Then they were evaluated by computed tomography angiography of pulmonary arteries. The RV/LV diameter ratio and also pulmonary artery obstruction index (PAOI) were calculated. The patient's computed tomography scans were reviewed for pulmonary infarction. By adding the RV/LV ratio and pulmonary infarction to PAOI, a new index called the modified Qanadli score was made. Univariable and multivariable logistic regression was done for finding predictors of mortality. Results Nine cases (40%) of patients in the mortality group and 42 (20%) of survivors had ischemic heart disease and the difference was significantly meaningful. The mean Qanadli index in the mortality group was 16.8 ± 8.45 and in survivors was 8.3 ± 4.2. By adding the pulmonary infarction score and PAOI score to RV/LV ratio score, the odds ratio (OR) for predicting mortality increased significantly to 13 and 16, respectively, which were significantly meaningful. Based on our findings, the highest OR for predicting short-term mortality was obtained through a combined Qanadli index (PAOI score + pulmonary infarction score + RV/LV score) that was 17 in univariable and 18 in multivariable logistic regression analysis ( p -value = 0.015). Conclusion The new combined Qanadli index has more ability than the Qanadli index and RV/LV ratio for predicting changes in cardiovascular parameters and short-term mortality in patients with pulmonary embolism.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, University of California San Diego, Hillcrest Hospital, San Diego, California, United States
| | - Sonia Sedghian
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Siami
- Department of Statistics, Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Iman Yazdani nia
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Naseri
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Reza Hazara
- Department of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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10
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Gharepapagh E, Rahimi F, Koohi A, Bakhshandeh H, Mousavi-Aghdas SA, Sadeghipoor P, Fakhari A, Amirnia M, Javadrashid R, Rashidi F. Clot Burden As a Predictor of Chronic Thromboembolic Pulmonary Hypertension After Acute Pulmonary Embolism: A Cohort Study. THORACIC RESEARCH AND PRACTICE 2023; 24:276-281. [PMID: 37712867 PMCID: PMC10544596 DOI: 10.5152/thoracrespract.2023.22160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/04/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE A small percentage of acute pulmonary thromboembolisms (PTE) persist as chronic fibrin clots, potentially leading to chronic thromboembolic pulmonary hypertension (CTEPH). A scoring system for evaluating the burden of acute PTE based on computed tomography pulmonary angiogram (CTPA) findings was tested for its association with CTEPH within one year. MATERIAL AND METHODS In this retrospective cohort of 475 patients with a definitive diagnosis of acute PTE, the Qanadli score (QS) was calculated on the initial CTPA. Through regular follow-up over 1 year, symptomatic patients underwent extensive evaluation. RESULTS Of the 475 patients enrolled in the study [age 58.3 ± 16.6, 195 (41.1%) female, QS: 13.01 ± 7.37/40], 321 patients completed the study. A total of 22 (6.8%) patients were definitively diagnosed with CTEPH. In univariate analysis, the initial QS was significantly higher in patients with subsequent CTEPH than in patients without (17 ± 5.6 vs. 13 ± 7.6, P = .009). QS was directly associated with CTEPH (odds ratio: 1.08, 95% confidence interval: 1.0-1.16, P = .042). The evolution of CTEPH in men could be predicted with a sensitivity of 100% and a specificity of 54% when a cut-off point of 14.5 (43.5%) was set for QS. The area under the receiver operating characteristic curve in this setting was 0.74 with a P-value of .032. Qanadli score failed to predict CTEPH in women. CONCLUSION Scoring the clot burden in the pulmonary arteries through the Qanadli method can predict the evolution of CTEPH only in men 1 year after acute PTE. Women comprise most of the CTEPH patients. Thus, strict follow-up adherence seems to be even more important in women.
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Affiliation(s)
- Esmaeil Gharepapagh
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Rahimi
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Mousavi-Aghdas
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parham Sadeghipoor
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ashraf Fakhari
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrad Amirnia
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Javadrashid
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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11
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Casey SD, Zekar L, Somers MJ, Westafer LM, Reed ME, Vinson DR. Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism. Ann Emerg Med 2023; 82:369-380. [PMID: 37028997 PMCID: PMC11126867 DOI: 10.1016/j.annemergmed.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
STUDY OBJECTIVE Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
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Affiliation(s)
- Scott D Casey
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network.
| | - Lara Zekar
- Department of Emergency Medicine, University of California, Davis, CA
| | - Madeline J Somers
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, MA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
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12
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Hakgör A, Ceren Tokgöz Demircan H, Keskin B, Tanyeri S, Kültürsay B, Tosun A, Yaşar Akbal Ö, Külahçıoğlu Ş, Karagöz A, Türkday Derebey S, Bayram Z, Çağan Efe S, Doğan C, Halil Tanboğa İ, Özdemir N, Kaymaz C. A Novel Composed Index to Evaluate the Right Ventricle Free-Wall Adaptation Against Ventricular Wall Stress in Acute Pulmonary Embolism. Anatol J Cardiol 2023; 27:423-431. [PMID: 37288851 PMCID: PMC10339144 DOI: 10.14744/anatoljcardiol.2023.2677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/27/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism severity index and simplified pulmonary embolism severity index have been utilized in initial risk evaluation in patients with acute pulmonary embolism. However, these models do not include any imaging measure of right ventricle function. In this study, we proposed a novel index and aimed to evaluate the clinical impact. METHODS Our study population comprised retrospectively evaluated 502 patients with acute pulmonary embolism managed with different treatment modalities. Echocardiographic and computed tomographic pulmonary angiography evaluations were performed at admission to the emergency room within maximally 30 minutes. The formula of our index was as follows: (right ventricle diameter × systolic pulmonary arterial pressure-echo)/(right ventricle free-wall diameter × tricuspid annular plane systolic excursion). RESULTS This index value showed significant correlations to clinical and hemodynamic severity measures. Only pulmonary embolism severity index, but not our index value, independently predicted in-hospital mortality. However, an index value higher than 17.8 predicted the long-term mortality with a sensitivity of 70% and specificity of 40% (areas under the curve = 0.652, 95% CI, 0.557-0.747, P =.001). According to the adjusted variable plot, the risk of long-term mortality increased until an index level of 30 but remained unchanged thereafter. The cumulative hazard curve also showed a higher mortality with high-index value versus low-index value. CONCLUSIONS Our index composed from measures of computed tomographic pulmonary angiography and transthoracic echocardiography may provide important insights regarding the adaptation status of right ventricle against pressure/wall stress in acute pulmonary embolism, and a higher value seems to be associated with severity of the clinical and hemodynamic status and long-term mortality but not with in-hospital mortality. However, the pulmonary embolism severity index remained as the only independent predictor for in-hospital mortality.
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Affiliation(s)
- Aykun Hakgör
- Department of Cardiology, Medipol Mega University Hospital, İstanbul, Turkey
| | - Hacer Ceren Tokgöz Demircan
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Berhan Keskin
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Seda Tanyeri
- Department of Cardiology, University of Health Sciences Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Barkın Kültürsay
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Ayhan Tosun
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Özgür Yaşar Akbal
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Şeyhmus Külahçıoğlu
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Ali Karagöz
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Sevim Türkday Derebey
- Department of Cardiology, University of Health Sciences, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Zübeyde Bayram
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Cem Doğan
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | | | - Nihal Özdemir
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
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13
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Isath A, Shah R, Bandyopadhyay D, Bali A, Kanwal A, Spevack D, Ranjan P, Goldberg JB. Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism). Am J Cardiol 2023; 201:341-348. [PMID: 37406578 DOI: 10.1016/j.amjcard.2023.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/19/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023]
Abstract
In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p = 0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p = 0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p = 0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p = 0.32). In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | - Ravi Shah
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | | | - Atul Bali
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | - Arjun Kanwal
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | - Daniel Spevack
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | - Pragya Ranjan
- Department of Cardiology, Westchester Medical Center, New York Medical College Valhalla, New York
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College Valhalla, New York.
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14
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Cantu-Martinez O, Martinez Manzano JM, Tito S, Prendergast A, Jarrett SA, Chiang B, Wattoo A, Azmaiparashvili Z, Lo KB, Benzaquen S, Eiger G. Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis. Respir Med 2023:107295. [PMID: 37236407 DOI: 10.1016/j.rmed.2023.107295] [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] [Received: 02/10/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE. METHODS Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality. RESULTS A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes. CONCLUSION Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.
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Affiliation(s)
- Omar Cantu-Martinez
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA.
| | | | - Sahana Tito
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Alexander Prendergast
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Simone A Jarrett
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Brenda Chiang
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Ammaar Wattoo
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Zurab Azmaiparashvili
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Sadia Benzaquen
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA; Department of Pulmonary and Critical Care Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Glenn Eiger
- Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA; Department of Pulmonary and Critical Care Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19414, USA
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15
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Peng R, Yin W, Wang F, Cong X, Lu B, Hua L, Chen X. Neutrophil levels upon admission for the assessment of acute pulmonary embolism with intermediate- and high-risk: an indicator of thrombosis and inflammation. Thromb J 2023; 21:28. [PMID: 36918857 PMCID: PMC10015714 DOI: 10.1186/s12959-023-00471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Risk prediction rules are important to establish appropriate treatment and management strategy for patients with different risk classification of pulmonary embolism (PE). Neutrophils are considered to be related to PE as an essential marker of inflammation. However, few studies have reported the association between neutrophil levels and risk classification of acute PE (APE). The aim of this study was to investigate the role of neutrophil levels upon admission in the assessment of risk classification of APE. METHODS A total of 299 consecutive APE patients and 90 patients without APE confirmed by computed tomographic pulmonary angiography were retrospectively screened. APE patients were stratified into two subgroups according to clinical guidelines: low- (n = 233) and intermediate- and high-risk (n = 60) APE. RESULTS The neutrophil levels in intermediate- and high-risk APE patients were significantly higher compared to low-risk APE or non-APE patients (P < 0.001). In multivariable logistic regression analysis, neutrophil levels were significantly and independently associated with intermediate- and high-risk APE (odds ratio = 1.239, 95% confidence interval [CI] 1.055-1.455, P = 0.009). Neutrophil levels were positively correlated with the pulmonary embolism severity index score (r = 0.357, P < 0.001), high sensitive C-reactive protein, D-dimer and pulmonary artery obstruction index (PAOI), in the overall population of APE patients. Receiver-operating characteristic curve analysis revealed that neutrophils had a better diagnostic value for intermediate- and high-risk APE (area under the curve [AUC] = 0.760, 95% CI 0.695-0.826; P < 0.001) compared to PAOI (AUC = 0.719) and D-dimer (AUC = 0.645). CONCLUSIONS High neutrophil levels upon admission were significantly and independently associated with intermediate- and high-risk APE, which could be regarded as an indicator of inflammation and thrombosis in APE simultaneously. The potent diagnostic role of neutrophil levels and their competitive advantage over PAOI and D-dimer for the assessment of APE risk classification are suggested.
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Affiliation(s)
- Rui Peng
- Center of Clinical Laboratory, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Diagnostic Laboratory Service, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weihua Yin
- Department of Radiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Wang
- Diagnostic Laboratory Service, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangfeng Cong
- Diagnostic Laboratory Service, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Lu
- Department of Radiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Key Laboratory of Pulmonary Vascular Medicine & State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Xi Chen
- Diagnostic Laboratory Service, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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16
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Keller K, Schmitt VH, Ostad MA, Münzel T, Hobohm L, Espinola‐Klein C. Mansoor's Self-Report Tool for Cardiovascular Risk Assessment predicts adverse in-hospital events in patients with pulmonary embolism. THE CLINICAL RESPIRATORY JOURNAL 2022; 17:80-89. [PMID: 36544042 PMCID: PMC9892697 DOI: 10.1111/crj.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a life-threatening acute disease accompanied by high morbidity and mortality. Regarding hospitalizations of patients with PE, risk stratification of these patients is crucial. Thus, risk stratification tools like risk scores are of key interest. METHODS The nationwide German inpatient sample of the years 2005-2018 was used for this present analysis. Hospitalized PE patients were stratified according to Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class, and the performance of this score was evaluated to predict adverse in-hospital events. RESULTS Overall, 1 174 196 hospitalizations of PE patients (53.5% females; 56.4% ≥70 years) were registered in Germany between 2005 and 2018. According to the Mansoor's self-report tool for cardiovascular risk assessment, 346 126 (29.5%) PE patients were classified as high risk. Higher Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class was predictive for in-hospital death (OR 1.129 [95%CI 1.117-1.141], P < 0.001), shock (OR 1.117 [95%CI 1.095-1.140], P < 0.001), cardiopulmonary resuscitation (OR 1.109 [95%CI 1.092-1.126], P < 0.001), right ventricular dysfunction (OR 1.039 [95%CI 1.030-1.048], P < 0.001), intracerebral bleeding (OR 1.316 [95%CI 1.275-1.358], P < 0.001), and gastro-intestinal bleeding (OR 1.316 [95%CI 1.275-1.358], P < 0.001). Systemic thrombolysis was not associated with lower in-hospital mortality in high-risk class (OR 5.139 [95%CI 4.961-5.323], P < 0.001). CONCLUSIONS Prognostic performance of the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment for risk stratification of PE patients was poor and not able to identify those PE patients, who might benefit from systemic thrombolysis. However, the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment was moderately helpful to identify PE patients at higher risk for bleeding events.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Medical Clinic VII, Department of Sports MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Volker H. Schmitt
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,German Center for Cardiovascular Research (DZHK), Partner Site Rhine MainMainzGermany
| | - Mir A. Ostad
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Thomas Münzel
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,German Center for Cardiovascular Research (DZHK), Partner Site Rhine MainMainzGermany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Christine Espinola‐Klein
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
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17
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Lerchbaumer MH, Aviram G, Ebner M, Ritter CO, Steimke L, Rozenbaum Z, Adam SZ, Granot Y, Hasenfuß G, Lotz J, Hamm B, Konstantinides SV, Lankeit M. Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism. Eur J Radiol 2022; 157:110554. [PMID: 36308850 DOI: 10.1016/j.ejrad.2022.110554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/01/2022] [Accepted: 10/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE). METHODS On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. RESULTS Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients. CONCLUSION A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.
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Affiliation(s)
| | - Galit Aviram
- Department of Radiology, Tel Aviv Medical Centre, Tel Aviv, Israel(2)
| | - Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Christian O Ritter
- Institute for Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany
| | - Laura Steimke
- Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany
| | - Zach Rozenbaum
- Department of Cardiology, Tel Aviv Medical Centre, Tel Aviv, Israel(3)
| | - Sharon Z Adam
- Department of Radiology, Tel Aviv Medical Centre, Tel Aviv, Israel(2)
| | - Yoav Granot
- Department of Cardiology, Tel Aviv Medical Centre, Tel Aviv, Israel(3)
| | - Gerd Hasenfuß
- German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany; Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany
| | - Bernd Hamm
- Department of Radiology, Charité - University Medicine Berlin, Germany
| | - Stavros V Konstantinides
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
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18
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Ak M, Gumus S, Aghayev A, Chang CH, Fu B, Roberts MS, Woodard PK, Bae KT. The Resolution Rate of Pulmonary Embolism on CT Pulmonary Angiography: a Prospective Study. Eur J Radiol 2022; 155:110466. [PMID: 35986988 DOI: 10.1016/j.ejrad.2022.110466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/25/2022] [Accepted: 08/06/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To prospectively assess the rate of clot resolution from CT pulmonary angiography (CTPA) in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS This prospective cohort study included 290 patients (136 men, 154 women; mean age, 51.9 years) with acute PE. All patients had a CTPA at the presentation and had at least one follow-up within 6 months (mean 72.7 days). Sixty-four percent of patients had follow-up scans for research purposes within a pre-determined period (between 28 and 184 days; mean, 78.27 days) and 36 % had (between 2 and 184 days; mean, 62.78 days) for a clinical indication. The volume of each clot was measured using a semi-automated quantification program. The resolution rate was evaluated by interval-censored analysis. RESULTS The overall estimated probability of complete resolution was 42 % at 7 days, 56 % at 10 days, and 71 % at 45 days. Achieving complete resolution was significantly faster in patients with peripheral clots (HR: 1.78; CI: 1.05-3.03, p = 0.032) but slower in patients with consolidation and history of venous thromboembolism (VTE), (HR: 0.37; CI: 0.18-0.79, p = 0.01 and HR: 0.57; CI: 0.35-0.91, p = 0.019, respectively). Although the patients with cancer showed a faster resolution rate (HR: 1.67; CI: 1.05-2.68, p = 0.032), the mortality rate was significantly higher than non-cancer patients. CONCLUSION The resolution rate of clot burden in acute PE was associated with patients' clinical presentation variables and CTPA imaging biomarkers. This information may be incorporated into designing a prediction rule and determining the appropriate duration of anticoagulation therapy in patients with acute PE.
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Affiliation(s)
- M Ak
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - S Gumus
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - A Aghayev
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - C H Chang
- Department of Medicine, School of Medicine, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - B Fu
- Data and Statistical Sciences, Abbvie, Inc., Lake Bluff, IL, United States
| | - M S Roberts
- Department of Medicine, School of Medicine, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - P K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, United States
| | - K T Bae
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Harvey JJ, Huang S, Uberoi R. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev 2022; 8:CD013083. [PMID: 35938605 PMCID: PMC9358724 DOI: 10.1002/14651858.cd013083.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) is a major cause of acute morbidity and mortality. APE results in long-term morbidity in up to 50% of survivors, known as post-pulmonary embolism (post-PE) syndrome. APE can be classified according to the short-term (30-day) risk of mortality, based on a variety of clinical, imaging and laboratory findings. Most mortality and morbidity is concentrated in high-risk (massive) and intermediate-risk (submassive) APE. The first-line treatment for APE is systemic anticoagulation. High-risk (massive) APE accounts for less than 10% of APE cases and is a life-threatening medical emergency, requiring immediate reperfusion treatment to prevent death. Systemic thrombolysis is the recommended treatment for high-risk (massive) APE. However, only a minority of the people affected receive systemic thrombolysis, due to comorbidities or the 10% risk of major haemorrhagic side effects. Of those who do receive systemic thrombolysis, 8% do not respond in a timely manner. Surgical pulmonary embolectomy is an alternative reperfusion treatment, but is not widely available. Intermediate-risk (submassive) APE represents 45% to 65% of APE cases, with a short-term mortality rate of around 3%. Systemic thrombolysis is not recommended for this group, as major haemorrhagic complications outweigh the benefit. However, the people at higher risk within this group have a short-term mortality of around 12%, suggesting that anticoagulation alone is not an adequate treatment. Identification and more aggressive treatment of people at intermediate to high risk, who have a more favourable risk profile for reperfusion treatments, could reduce short-term mortality and potentially reduce post-PE syndrome. Catheter-directed treatments (catheter-directed thrombolysis and catheter embolectomy) are minimally invasive reperfusion treatments for high- and intermediate-risk APE. Catheter-directed treatments can be used either as the primary treatment or as salvage treatment after failure of systemic thrombolysis. Catheter-directed thrombolysis administers 10% to 20% of the systemic thrombolysis dose directly into the thrombus in the lungs, potentially reducing the risks of haemorrhagic side effects. Catheter embolectomy mechanically removes the thrombus without the need for thrombolysis, and may be useful for people with contraindications for thrombolysis. Currently, the benefits of catheter-based APE treatments compared with existing medical and surgical treatment are unclear despite increasing adoption of catheter treatments by PE response teams. This review examines the evidence for the use of catheter-directed treatments in high- and intermediate-risk APE. This evidence could help guide the optimal treatment strategy for people affected by this common and life-threatening condition. OBJECTIVES To assess the effects of catheter-directed therapies versus alternative treatments for high-risk (massive) and intermediate-risk (submassive) APE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 15 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of catheter-directed therapies for the treatment of high-risk (massive) and intermediate-risk (submassive) APE. We excluded catheter-directed treatments for non-PE. We applied no restrictions on participant age or on the date, language or publication status of RCTs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. The main outcomes were all-cause mortality, treatment-associated major and minor haemorrhage rates based on two established clinical definitions, recurrent APE requiring retreatment or change to a different APE treatment, length of hospital stay, and quality of life. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We identified one RCT (59 participants) of (ultrasound-augmented) catheter-directed thrombolysis for intermediate-risk (submassive) APE. We found no trials of any catheter-directed treatments (thrombectomy or thrombolysis) in people with high-risk (massive) APE or of catheter-based embolectomy in people with intermediate-risk (submassive) APE. The included trial compared ultrasound-augmented catheter-directed thrombolysis with alteplase and systemic heparinisation versus systemic heparinisation alone. In the treatment group, each participant received an infusion of alteplase 10 mg or 20 mg over 15 hours. We identified a high risk of selection and performance bias, low risk of detection and reporting bias, and unclear risk of attrition and other bias. Certainty of evidence was very low because of risk of bias and imprecision. By 90 days, there was no clear difference in all-cause mortality between the treatment group and control group. A single death occurred in the control group at 20 days after randomisation, but it was unrelated to the treatment or to APE (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.01 to 7.96; 59 participants). By 90 days, there were no episodes of treatment-associated major haemorrhage in either the treatment or control group. There was no clear difference in treatment-associated minor haemorrhage between the treatment and control group by 90 days (OR 3.11, 95% CI 0.30 to 31.79; 59 participants). By 90 days, there were no episodes of recurrent APE requiring retreatment or change to a different APE treatment in the treatment or control group. There was no clear difference in the length of mean total hospital stay between the treatment and control groups. Mean stay was 8.9 (standard deviation (SD) 3.4) days in the treatment group versus 8.6 (SD 3.9) days in the control group (mean difference 0.30, 95% CI -1.57 to 2.17; 59 participants). The included trial did not investigate quality of life measures. AUTHORS' CONCLUSIONS: There is a lack of evidence to support widespread adoption of catheter-based interventional therapies for APE. We identified one small trial showing no clear differences between ultrasound-augmented catheter-directed thrombolysis with alteplase plus systemic heparinisation versus systemic heparinisation alone in all-cause mortality, major and minor haemorrhage rates, recurrent APE and length of hospital stay. Quality of life was not assessed. Multiple small retrospective case series, prospective patient registries and single-arm studies suggest potential benefits of catheter-based treatments, but they provide insufficient evidence to recommend this approach over other evidence-based treatments. Researchers should consider clinically relevant primary outcomes (e.g. mortality and exercise tolerance), rather than surrogate markers (e.g. right ventricular to left ventricular (RV:LV) ratio or thrombus burden), which have limited clinical utility. Trials must include a control group to determine if the effects are specific to the treatment.
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Affiliation(s)
- John J Harvey
- Trinity College, University of Oxford, Oxford, UK
- Department of Radiology, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Shiwei Huang
- Department of Radiology, St George Hospital, Kogarah, Australia
| | - Raman Uberoi
- Department of Radiology, John Radcliffe NHS Trust Hospital, Oxford, UK
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Farag A, Fielding J, Catanzano T. Role of Dual-energy Computed Tomography in Diagnosis of Acute Pulmonary Emboli, a Review. Semin Ultrasound CT MR 2022; 43:333-343. [PMID: 35738818 DOI: 10.1053/j.sult.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Prompt diagnosis of pulmonary embolism is essential to avert morbidity and mortality. There are a number of diagnostic options for identification of a pulmonary embolism, including laboratory and imaging investigations. While computed tomography pulmonary angiography (CTPA) has largely supplanted nuclear medicine ventilation/perfusion studies, there remain significant limitations in the optimal performance of CTPA. Dual-energy computed tomography has the ability to overcome many of the limitations of standard of care CTPA, including rescue of poor contrast boluses and the ability to evaluate pulmonary perfusion defects.
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Affiliation(s)
- Ahmed Farag
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Jordan Fielding
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA.
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Zuin M, Rigatelli G, Bilato C, Bongarzoni A, Casazza F, Zonzin P, Roncon L. Prognostic role of serial electrocardiographic changes in patients with acute pulmonary embolism. Data from the Italian Pulmonary Embolism Registry. Thromb Res 2022; 217:15-21. [PMID: 35841712 DOI: 10.1016/j.thromres.2022.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | - Gianluca Rigatelli
- Department of Interventional Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignagno, Vicenza, Italy
| | - Amedeo Bongarzoni
- Department of Cardiology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, Milan, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
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22
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Hajiahmadi S, Tabesh F, Shayganfar A, Shirani F, Ebrahimian S. Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism. RADIOLOGIA 2022. [DOI: 10.1016/j.rxeng.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Akagawa M, Kijima H, Kimura Y, Saito H, Saito K, Wakabayashi I, Kashiwagura T, Miyakoshi N. Fibrin monomer complex on postoperative day 1 is correlated with the volume of deep vein thrombosis after knee surgery. J Exp Orthop 2022; 9:47. [PMID: 35593965 PMCID: PMC9123101 DOI: 10.1186/s40634-022-00482-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/06/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Patients undergoing knee surgery are at high risk for deep vein thrombosis (DVT), which is infrequent but potentially life-threatening. It has not been identified how to efficiently detect high-risk DVT while minimizing bleeding complications from anticoagulation. We hypothesized that the degree of activation of thrombotic markers may correlate with the size of the thrombus. Therefore, we investigated the correlation between thrombotic markers and DVT thrombus volume in patients after knee surgery. METHODS This retrospective study involved 29 patients who underwent around knee osteotomy or total / unicompartmental knee arthroplasty from 2018 to 2020. Fibrin monomer complex (FMC) at 1, and 7 days after surgery, and D-dimer at 4, and 7 days after surgery were investigated. In addition, the volume of DVT was estimated with ultrasonography at the 7 days after surgery. Body mass index, surgical time, and total volume of blood loss were also evaluated. Factors related to thrombus volume were examined statistically. RESULTS Nine patients (31.0%) exhibited asymptomatic distal DVT, whereas 1 patient (3.4%) experienced asymptomatic proximal DVT. No patients had pulmonary embolism. Statistical analysis showed that only FMC concentration on postoperative day 1 was significantly correlated with thrombus volume (p < 0.001, 95% confidence interval 0.41 to 0.839, r = 0.679). CONCLUSIONS The FMC concentration was a useful early indicator of deep vein thrombosis after knee surgery. Monitoring the FMC concentration could enable selective identification of patients with a high thrombus volume, which is associated with a high risk for pulmonary embolism.
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Affiliation(s)
- Manabu Akagawa
- Department of Orthopedic Surgery, Omagari Kousei Medical Center, 8-65 Omagari-torimachi, Daisen, Akita, 014-0027, Japan.
| | - Hiroaki Kijima
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yoshiaki Kimura
- Department of Orthopedic Surgery, Akita City Hospital, 4-30 Kawamoto-Matsuokacho, Akita, 010-0933, Japan
| | - Hidetomo Saito
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Kimio Saito
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Ikuko Wakabayashi
- Department of Orthopedic Surgery, Akita City Hospital, 4-30 Kawamoto-Matsuokacho, Akita, 010-0933, Japan
| | - Takeshi Kashiwagura
- Department of Orthopedic Surgery, Akita City Hospital, 4-30 Kawamoto-Matsuokacho, Akita, 010-0933, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Quantitative volumetric computed tomography embolic analysis, the Qanadli score, biomarkers, and clinical prognosis in patients with acute pulmonary embolism. Sci Rep 2022; 12:7620. [PMID: 35538102 PMCID: PMC9090848 DOI: 10.1038/s41598-022-11812-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 04/18/2022] [Indexed: 11/09/2022] Open
Abstract
Detailed descriptions of acute pulmonary emboli (PE) morphology, total embolic volume (TEV), and their effects upon patients’ clinical presentation and prognosis remain largely unexplored. We studied 201 subjects with acute PE to the emergency department of a single medical center from April 2009 to December 2014. Patient hemodynamics, Troponin I and D-dimer levels, echocardiography, and the 30-day, 90-day and long-term mortality were obtained. Contrast-enhanced computed tomography (CT) of pulmonary structures and 3-dimensional measures of embolic burden were performed. The results showed a linear association between the greater TEV and each of the following 4 variables (increasing incidence of right ventricular (RV) dysfunction, higher systolic pulmonary artery pressure (sPAP), greater RV diameter, and RV/left ventricular (LV) ratio (all p < 0.001)). Among the measures of CT and echocardiography, TEV and RV/LV ratio were significantly associated with impending shock. In backward stepwise logistic regression, TEV, age and respiratory rate remained independent associated with impending shock (OR: 1.58, 1.03, 1.18, respectively and all p < 0.005).Total embolic burden assessed by CT-based quantification serves as a useful index for stressed cardiopulmonary circulation condition and can provide insights into RV dysfunction and the prediction of impending shock.
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Alirezaei T, Mahboubi-Fooladi Z, Irilouzadian R, Saberi Shahrbabaki A, Golestani H. CHA 2 DS 2 -VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism. Clin Cardiol 2022; 45:224-230. [PMID: 35132667 PMCID: PMC8860482 DOI: 10.1002/clc.23786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA2 DS2 -VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation. HYPOTHESIS This study aims to evaluate the association between CHA2 DS2 -VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA). METHODS One hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA2 DS2 -VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA. RESULTS PESI and CHA2 DS2 -VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA2 DS2 -VASc score and PESI score had a positive correlation. The area under the curve value for the CHA2 DS2 -VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity. CONCLUSION This study showed that not only CHA2 DS2 -VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA2 DS2 -VASc and PESI scores are able to predict RV dysfunction.
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Affiliation(s)
- Toktam Alirezaei
- Clinical Research Development Unit, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Rana Irilouzadian
- Clinical Research Development Unit, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Haniyeh Golestani
- Clinical Research Development Unit, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Piazza G. Off the beaten path: the need for innovation in medical therapy to improve outcomes in acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:10-12. [PMID: 34725676 DOI: 10.1093/ehjacc/zuab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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Zhang H, Cheng Y, Chen Z, Cong X, Kang H, Zhang R, Guo X, Liu M. Clot burden of acute pulmonary thromboembolism: comparison of two deep learning algorithms, Qanadli score, and Mastora score. Quant Imaging Med Surg 2022; 12:66-79. [PMID: 34993061 DOI: 10.21037/qims-21-140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The deep learning convolution neural network (DL-CNN) benefits evaluating clot burden of acute pulmonary thromboembolism (APE). Our objective was to compare the performance of the deep learning convolution neural network trained by the fine-tuning [DL-CNN (ft)] and the deep learning convolution neural network trained from the scratch [DL-CNN (fs)] in the quantitative assessment of APE. METHODS We included the data of 680 cases for training DL-CNN by DL-CNN (ft) and DL-CNN (fs), then retrospectively included 410 patients (137 patients with APE, 203 males, mean age 60.3±11.4 years) for testing the models. The distribution and volume of clots were respectively assessed by DL-CNN(ft) and DL-CNN(fs), and sensitivity, specificity, and area under the curve (AUC) were used to evaluate their performances in detecting clots on a per-patient and clot level. Radiologists evaluated the distribution of clots, Qanadli score, and Mastora score and right ventricular metrics, and the correlation of clot volumes with right ventricular metrics were analyzed with Spearman correlation analysis. RESULTS On a per-patient level, the two DL-CNN models had high sensitivities and moderate specificities [DL-CNN (ft): 100% and 77.29%; DL-CNN (fs): 100% and 75.82%], and their AUCs were comparable (Z=0.30, P=0.38). On a clot level, DL-CNN (ft) and DL-CNN (fs) sensitivities and specificities in detecting central clots were 99.06% and 72.61%, and 100% and 70.63%, respectively. DL-CNN (ft) sensitivities and specificities in detecting peripheral clots were mostly higher than those of DL-CNN (fs), and their AUCs were comparable. Clot volumes measured with the two models were similar (U=85094.500, P=0.741), and significantly correlated with Qanadli scores [DL-CNN(ft) r=0.825, P<0.001, DL-CNN(fs) r=0.827, P<0.001] and Mastora scores [DL-CNN(ft) r=0.859, P<0.001, DL-CNN(fs) r=0.864, P<0.001]. Clot volumes were also correlated with right ventricular metrics. Clot burdens were increased in the low-risk, moderate-risk, and high-risk patients. Binary logistic regression revealed that only the ratio of right ventricular area/left ventricular area (RVa/LVa) was an independent predictor of in-hospital death (odds ratio 6.73; 95% CI, 2.7-18.12, P<0.001). CONCLUSIONS Both DL-CNN (ft) and DL-CNN (fs) have high sensitivities and moderate specificities in detecting clots associated with APE, and their performances are comparable. While clot burdens quantitatively calculated by the two DL-CNN models are correlated with right ventricular function and risk stratification, RVa/LVa is an independent prognostic factor of in-hospital death in patients with APE.
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Affiliation(s)
- Hongxia Zhang
- Department of Radiology, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Capital Medical University School of Rehabilitation Medicine, Beijing, China
| | - Yan Cheng
- Intensive Care Unit, Erlonglu Hospital of Beijing, Beijing, China
| | - Zhenbo Chen
- Department of Radiology, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Capital Medical University School of Rehabilitation Medicine, Beijing, China
| | - Xinying Cong
- Department of Radiology, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Capital Medical University School of Rehabilitation Medicine, Beijing, China
| | - Han Kang
- Institute of AI-Advanced Research, Infervision Medical Technology Co., Ltd., Beijing, China
| | - Rongguo Zhang
- Institute of AI-Advanced Research, Infervision Medical Technology Co., Ltd., Beijing, China
| | - Xiaojuan Guo
- Department of Radiology, Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
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Xia W, Yu H, Chen W, Chen B, Huang Y. A Radiological Nomogram to Predict 30-day Mortality in Patients with Acute Pulmonary Embolism. Acad Radiol 2021; 29:1169-1177. [PMID: 34953727 DOI: 10.1016/j.acra.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
RATIONALE AND OBJECTIVES Acute pulmonary embolism (APE) is a common disease with a high mortality, especially in the short term. Computed tomographic pulmonary angiography (CTPA) is a recommended method in the diagnostic workup for APE; thus, this study aimed to establish a CTPA-based radiological nomogram to predict the 30-day mortality in patients with APE, and to further compare this model with the pulmonary embolism severity index (PESI) and simplified pulmonary embolism severity index (SPESI). MATERIALS AND METHODS We retrospectively recruited 158 adults with confirmed APE who underwent CTPA from August 1, 2017, to August 1, 2020. These adults were stratified into two groups according to their 30-day mortality. CTPA-based variables were analyzed using univariate and multivariate analyses, independent risk factors for 30-day mortality were established, and a radiological nomogram was constructed. Subsequently, PESI and SPESI were calculated. The performance of the radiological nomogram model was compared to that of the PESI and SPESI using decision curve analysis and receiver-operating characteristic curve analysis. RESULTS Thirty-three patients died within 30 days (30-day mortality rate, 20.9%). On logistic regression analysis, the right and left ventricular diameter ratio (odds ratio [OR] = 8.709, 95% confidence interval [CI]: 1.085-69.903, p = 0.042), ventricular septal bowing (OR = 8.085, 95% CI: 1.947-33.567, p = 0.004), chronic bronchitis (OR = 4.383, 95% CI: 1.025-18.740, p = 0.046), malignant lung lesions (OR = 17.530, 95% CI: 2.408-127.636, p = 0.005), and pneumonia (OR = 3.477, 95% CI: 1.123-10.766, p = 0.031) were identified as the independent predictors of 30-day mortality. The area under the curve of the radiological nomogram, PESI, and SPESI were 0.900 (95% CI: 0.828-0.971), 0.729 (95% CI: 0.642-0.815), and 0.718 (95% CI: 0.621-0.815), respectively. CONCLUSION The CTPA-based radiological nomogram appeared valuable for the prediction of 30-day mortality in patients with APE, and was superior to both PESI and SPESI.
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Significance of Right-to-Left Ventricular Ratio as a Quantitative Computed Tomography Biomarker in Patients With Negative Computed Tomography Pulmonary Angiograms. J Thorac Imaging 2021; 37:181-186. [DOI: 10.1097/rti.0000000000000630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Newcomb G, Wilson BL, White RJ, Goldman B, Lachant NA, Lachant DJ. An Untapped Resource: Characteristics of Thrombus Recovered from Intermediate or High Risk Pulmonary Embolus Patients. Cardiovasc Pathol 2021; 57:107392. [PMID: 34718141 DOI: 10.1016/j.carpath.2021.107392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/13/2021] [Accepted: 10/17/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Response to anticoagulation varies during management of acute hospitalized pulmonary embolism. We aimed to study thrombus histology in pulmonary embolism samples removed during acute surgical embolectomy to evaluate whether thrombus morphology was similar between patients and whether there was an association with duration of symptoms and/or resolution on follow up imaging. METHODS This was a retrospective observational single center study at the University of Rochester Medical Center. We evaluated patients that underwent acute surgical embolectomy and followed up in our clinic 2-4 months after the event with Ventilation/Perfusion (V/Q) scan obtained for all regardless of symptoms. Thromboemboli were formalin fixed and processed for light microscopy in the hospital histopathology laboratory. Four-micron thick sections were stained with hematoxylin and eosin, Masson trichrome, and Verhoeff elastic tissue stains. Immunohistochemistry was performed using anti-CD31 and anti-CD68. Slides were independently evaluated for time-dependent microscopic changes using Irniger's classification by two blinded pathologists. RESULTS Sixteen patients underwent embolectomy with fifteen having V/Q imaging at follow up. The majority of patients were female. Samples showed a generally similar overall architecture that included a central core composed primarily of red blood cells and fibrin and an outer layer of platelets and monocytes. Two samples had evidence of fibrosis and recanalization. CONCLUSIONS We found heterogeneous histopathology in samples obtained during acute embolectomy. Further prospective studies should systematically characterize clot morphology and evaluate treatment response and outcomes. Careful thrombus specimen measurement and consistent sampling for sections will be required to draw firm conclusions.
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Affiliation(s)
- Geoffrey Newcomb
- Department of Internal Medicine, University of Rochester Medical Center, Rochester, NY
| | - Bennett L Wilson
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Bruce Goldman
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Neil A Lachant
- Division of Hematology and Oncology at the Wilmot Cancer Center, University of Rochester, Rochester, NY
| | - Daniel J Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY.
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Hunsaker AR. Deep Learning and Risk Assessment in Acute Pulmonary Embolism. Radiology 2021; 302:185-186. [PMID: 34581632 DOI: 10.1148/radiol.2021211897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andetta R Hunsaker
- From the Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
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Fink MA, Mayer VL, Schneider T, Seibold C, Stiefelhagen R, Kleesiek J, Weber TF, Kauczor HU. CT Angiography Clot Burden Score from Data Mining of Structured Reports for Pulmonary Embolism. Radiology 2021; 302:175-184. [PMID: 34581626 DOI: 10.1148/radiol.2021211013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Many studies emphasize the role of structured reports (SRs) because they are readily accessible for further automated analyses. However, using SR data obtained in clinical routine for research purposes is not yet well represented in literature. Purpose To compare the performance of the Qanadli scoring system with a clot burden score mined from structured pulmonary embolism (PE) reports from CT angiography. Materials and Methods In this retrospective study, a rule-based text mining pipeline was developed to extract descriptors of PE and right heart strain from SR of patients with suspected PE between March 2017 and February 2020. From standardized PE reporting, a pulmonary artery obstruction index (PAOI) clot burden score (PAOICBS) was derived and compared with the Qanadli score (PAOIQ). Scoring time and confidence from two independent readings were compared. Interobserver and interscore agreement was tested by using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. To assess conformity and diagnostic performance of both scores, areas under the receiver operating characteristic curve (AUCs) were calculated to predict right heart strain incidence, as were optimal cutoff values for maximum sensitivity and specificity. Results SR content authored by 67 residents and signed off by 32 consultants from 1248 patients (mean age, 63 years ± 17 [standard deviation]; 639 men) was extracted accurately and allowed for PAOICBS calculation in 304 of 357 (85.2%) PE-positive reports. The PAOICBS strongly correlated with the PAOIQ (r = 0.94; P < .001). Use of PAOICBS yielded overall time savings (1.3 minutes ± 0.5 vs 3.0 minutes ± 1.7), higher confidence levels (4.2 ± 0.6 vs 3.6 ± 1.0), and a higher ICC (ICC, 0.99 vs 0.95), respectively, compared with PAOIQ (each, P < .001). AUCs were similar for PAOICBS (AUC, 0.75; 95% CI: 0.70, 0.81) and PAOIQ (AUC, 0.77; 95% CI: 0.72, 0.83; P = .68), with cutoff values of 27.5% for both scores. Conclusion Data mining of structured reports enabled the development of a CT angiography scoring system that simplified the Qanadli score as a semiquantitative estimate of thrombus burden in patients with pulmonary embolism. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Hunsaker in this issue.
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Affiliation(s)
- Matthias A Fink
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Victoria L Mayer
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Thomas Schneider
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Constantin Seibold
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Rainer Stiefelhagen
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Jens Kleesiek
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Tim F Weber
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
| | - Hans-Ulrich Kauczor
- From the Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany (M.A.F., V.L.M., T.S., T.F.W., H.U.K.); Institute for Anthropomatics and Robotics (IAR), Karlsruhe Institute of Technology, Karlsruhe, Germany (C.S., R.S.); and Institute for AI in Medicine (IKIM), University Hospital Essen, Essen, Germany (J.K.)
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Schmitz A, Schacht M, Butty S. Repeat angiography in patients undergoing conventional catheter-directed thrombolysis for submassive pulmonary embolism: a large single-center experience. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:664-670. [PMID: 34559051 DOI: 10.5152/dir.2021.20573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Few studies have examined conventional catheter directed thrombolysis (CDT) for the treatment of submassive pulmonary embolism (PE). Moreover, angiographic resolution of thrombus burden following CDT has infrequently been characterized. This study describes a single-center experience treating submassive PE with CDT while utilizing repeat angiography to determine treatment efficacy. METHODS A retrospective analysis of 140 consecutive patients who underwent CDT for submassive PE from December 2012 to June 2019 was performed. Angiographic resolution of thrombus burden after CDT was reported as high (>75%), moderate (51-75%), low (26-50%), or insignificant (≤25%). All angiograms were reviewed by two interventional radiologists. Secondary endpoints included reduction in pulmonary artery pressure (PAP) and clinical outcomes. Bleeding events were classified according to the Society of Interventional Radiology (SIR) adverse event criteria. RESULTS CDT was performed in 140 patients with a mean rtPA dose of 25.3 mg and a mean treatment time of 26.0 hours. Angiographic resolution of thrombus burden was high in 70.0%, moderate in 19.3%, low in 5.7%, and insignificant in 3.6%; in 2 patients (1.4%) repeat angiography was not performed. Systolic PAP was reduced (47 vs. 35 mmHg, p < 0.001), mean PAP was reduced (25 vs 21 mmHg, p < 0.001), and 129 patients (92.1%) improved clinically. Patients with high or moderate resolution of thrombus burden had a clinical improvement rate of 95.2%, while patients with low or insignificant thrombus burden resolution had a clinical improvement rate of 76.9% (p=0.011). Ten patients (7.1%) had hemodynamic or respiratory decompensation requiring mechanical ventilation, systemic thrombolysis, cardiopulmonary resuscitation, or surgical intervention. Seven patients (5.0%) experienced moderate bleeding events and one patient (0.7%) with metastatic disease developed severe gastrointestinal bleeding that resulted in death. Thirty-day mortality was 1.4%. CONCLUSION In patients with submassive PE undergoing CDT, angiographic resolution of thrombus burden is a safe and directly observable metric that can be used to determine procedural success. In this study, CDT with repeat angiography was associated with a 5.7% bleeding event rate and thirty-day mortality of 1.4%.
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Affiliation(s)
- Adam Schmitz
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Michael Schacht
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Sabah Butty
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
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Jia D, Ji C, Zhao M. Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study. World J Emerg Med 2021; 12:261-267. [PMID: 34512821 DOI: 10.5847/wjem.j.1920-8642.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 04/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study. METHODS A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis. RESULTS Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively). CONCLUSIONS Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.
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Affiliation(s)
- Dong Jia
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Chao Ji
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Min Zhao
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
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Wu MA, Colombo R, Arquati M, Ippolito S, Taino A, Ruggiero D, Tonelli F, Trombetta L, Facchinetti P, Glielmo P, Cogliati C, Flor N. Clinical-radiological correlations in COVID-19-related venous thromboembolism: Preliminary results from a multidisciplinary study. Int J Clin Pract 2021; 75:e14370. [PMID: 33998752 PMCID: PMC8236936 DOI: 10.1111/ijcp.14370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Among the multiple complex pathophysiological mechanisms underlying COVID-19 pneumonia, immunothrombosis has been shown to play a key role. One of the most dangerous consequences of the prothrombotic imbalance is the increased incidence of micro- and macrothrombotic phenomena, especially deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS We investigated the correlation between radiological and clinical-biochemical characteristics in a cohort of hospitalised COVID-19 patients. RESULTS PE was confirmed in 14/61 (23%) patients, five (35.7%) had DVT. The radiographic findings, quantified by Qanadli score calculated on CT angiography, correlated with the clinical score and biochemical markers. The ratio between the right and left ventricle diameter measured at CT angiography correlated with the length of hospital stay. CONCLUSION In our cohort radiological parameters showed a significant correlation with clinical prognostic indices and scores, thus suggesting that a multidisciplinary approach is advisable in the evaluation of PE in COVID-19 patients.
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Affiliation(s)
- Maddalena Alessandra Wu
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Riccardo Colombo
- Division of Anesthesiology and Intensive CareASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Massimo Arquati
- Division of Emergency MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Sonia Ippolito
- Department of RadiologyASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Alba Taino
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Diego Ruggiero
- Division of CardiologyASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Francesca Tonelli
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Lucia Trombetta
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Pietro Facchinetti
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Pierluigi Glielmo
- Postgraduation School in RadiodiagnosticsFacoltà di Medicina e ChirurgiaUniversity of MilanMilanItaly
| | - Chiara Cogliati
- Division of Internal MedicineASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
| | - Nicola Flor
- Department of RadiologyASST Fatebenefratelli SaccoLuigi Sacco HospitalUniversity of MilanMilanItaly
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Surov A, Akritidou M, Bach AG, Bailis N, Lerche M, Meyer HJ, Pech M, Wienke A. A New Index for the Prediction of 30-Day Mortality in Patients With Pulmonary Embolism: The Pulmonary Embolism Mortality Score (PEMS). Angiology 2021; 72:787-793. [PMID: 33557585 PMCID: PMC8326960 DOI: 10.1177/0003319721993346] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Our aim was to analyze possibility of combination of basic clinical and radiological signs to predict 30-day mortality after acute pulmonary embolism (PE). We included 486 patients. Age, gender, simplified pulmonary embolism index (sPESI), pH, troponin, N-terminal natriuretic peptide, minimal systolic and diastolic blood pressure, O2 saturation, syncope, need for vasopressors, thrombotic obstruction, vessel diameter, short axis ratio right ventricle/left ventricle, and contrast medium reflux into the inferior vena cava (IVC) were analyzed. A backward algorithm in a logistic regression model was used to identify relevant risk factors. Multiple logistic regression analysis identified that sPESI, pH, minimal diastolic blood pressure, IVC reflux, and need for vasopressors influenced 30-day mortality. A score for mortality prediction was constructed (the Pulmonary Embolism Mortality Score): sPESI >2 points (1 point), pH <7.35 (1 point), minimal diastolic blood pressure <45 mm Hg (1 point), IVC reflux (1 point), and need for vasopressors (2 points). Patients with >3 points showed higher 30-day mortality (sensitivity: 84.9%, specificity: 83.0%, positive predictive value: 51.8%, negative predictive value: 96.2%). The net reclassification improvement compared with the sPESI was 0.94 (95% CI = 0.73-1.15). In conclusion, a new score can predict 30-day mortality in patients with PE and is more sensitive than sPESI.
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Affiliation(s)
- Alexey Surov
- Department of Radiology, University of Leipzig, Germany
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Mideia Akritidou
- Department of Internal Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Gunther Bach
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Marianne Lerche
- Department of Respiratory Medicine, University of Leipzig, Germany
| | | | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Gao Y, Wang N, Li Y, Huang H, Jia D. Phenotyping of non-high-risk acute pulmonary embolism patients: different initial manifestations of clinical deterioration. Eur J Intern Med 2021; 90:116-118. [PMID: 34103221 DOI: 10.1016/j.ejim.2021.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Yizhuo Gao
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Na Wang
- Occupational Disease and Occupational Health Prevention and Control Institute, Liaoning Center for Disease Control and Prevention, Shenyang, Liaoning, China
| | - Yuhua Li
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Haofeng Huang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Dong Jia
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China.
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Rapid prediction of deterioration risk among non-high-risk patients with acute pulmonary embolism at admission: An imaging tool. Int J Cardiol 2021; 338:229-236. [PMID: 34139228 DOI: 10.1016/j.ijcard.2021.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/03/2021] [Accepted: 06/09/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Computed tomography (CT) pulmonary angiography as the first-line diagnosis tool of acute pulmonary embolism (PE), might improve this discriminatory power. We aimed to developed a simply tool combining multi-CT parameters to complete individualized risk assessment of deterioration in non-high-risk patients with acute PE at admission. METHOD Consecutive non-high-risk patients with acute PE who were treated in a Chinese center during 2010-2021, were collected.Prognosis-related CT parameters were reviewed. Deterioration was defined as any adverse event within 30 day after admission. Eligible patients were randomized into derivation and validation cohorts. In the derivation cohort, CT parameters were screened for importance using classification tree methodology and enrolled variables was partitioned via curve-fitting and dose-response analysis. A nomogram was developed and the predictive power in both cohorts was evaluated based on the area under the receiver operating characteristic curve (AUROC) and the corresponding 95% confidence interval (CI). RESULT A total of 1001 patients were included. The preliminary analyses revealed that deterioration risk was related to the right-to-left ventricular diameter ratio at 4-chamber view, pulmonary vein filling abnormality. After a curve-fitting to deterioration risk, these parameters were partitioned and used to develop a nomogram, which had AUROC values of 0.91 (95% CI: 0.87-0.96) in the derivation cohort and 0.89 (95% CI: 0.81-0.97) in the validation cohort. A web-based version of the radiomics scoring tool was published online for use in clinical practice (https://acutepeprediction.shinyapps.io/Radiomics_Predictive_Tool/). CONCLUSION This simply tool can complete rapid estimation of deterioration risk among non-high-risk acute PE patients at admission.
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Hajiahmadi S, Tabesh F, Shayganfar A, Shirani F, Ebrahimian S. Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism. RADIOLOGIA 2021; 65:S0033-8338(21)00076-X. [PMID: 33865608 DOI: 10.1016/j.rx.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/07/2021] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. MATERIALS AND METHODS In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. RESULTS PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). CONCLUSIONS PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.
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Affiliation(s)
- S Hajiahmadi
- Assistant Professor, Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - F Tabesh
- Assistant Professor, Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - A Shayganfar
- Assistant Professor, Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fattane Shirani
- Resident, Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - S Ebrahimian
- Postdoctoral researcher, Massachusetts General Hospital, United States of America
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Ammari Z, Hasnie AA, Ruzieh M, Dasa O, Al-Sarie M, Shastri P, Ashcherkin N, Brewster PS, Cooper CJ, Gupta R. Prognostic Value of Computed Tomography Versus Echocardiography Derived Right to Left Ventricular Diameter Ratio in Acute Pulmonary Embolism. Am J Med Sci 2021; 361:445-450. [DOI: 10.1016/j.amjms.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/02/2020] [Accepted: 07/07/2020] [Indexed: 01/14/2023]
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Nie Y, Sun L, Long W, LV X, Li C, Wang H, Li X, Han P, Guo M. Clinical importance of the distribution of pulmonary artery embolism in acute pulmonary embolism. J Int Med Res 2021; 49:3000605211004769. [PMID: 33823631 PMCID: PMC8033481 DOI: 10.1177/03000605211004769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/04/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore the clinical importance of the distribution of pulmonary artery embolism in acute pulmonary embolism (APE). METHODS Sixty-four patients with APE were classified into mixed-type and distal-type pulmonary embolism groups. Their right ventricular systolic pressure (RVSP) and disease duration were recorded, and the diameter of their right ventricles was measured by ultrasound. The computed tomography angiographic clot load was determined as a Mastora score. RESULTS Patients with distal-type pulmonary embolisms had significantly lower RVSPs (44.92 ± 17.04 vs 55.69 ± 17.66 mmHg), and significantly smaller right ventricular diameters (21.08 ± 3.06 vs 23.37 ± 3.48 mm) than those with mixed-type pulmonary embolisms. Additionally, disease duration was significantly longer in patients with distal-type pulmonary embolisms (14.33 ± 11.57 vs 8.10 ± 7.10 days), and they had significantly lower Mastora scores (20.91% ± 18.92% vs 43.96% ± 18.30%) than patients with mixed-type pulmonary embolisms. After treatment, RVSPs decreased significantly in patients with both distal-type and mixed-type pulmonary embolisms. Right ventricle diameters also decreased significantly in patients with mixed-type pulmonary embolisms after treatment. CONCLUSION Patients with mixed-type pulmonary embolisms are significantly more susceptible to pulmonary hypertension, enlarged right ventricular diameters, and shorter durations of disease than those with distal-type pulmonary embolisms. The distribution of pulmonary artery embolism in APE can provide a clinical reference.
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Affiliation(s)
- Yunqiang Nie
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Li Sun
- Department of Respiratory Medicine, Zaozhuang Municipal
Hospital, Zaozhuang, China
| | - Wei Long
- Department of Radiology, Linyi People’s Hospital, Linyi,
China
| | - Xin LV
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Cuiyun Li
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Hui Wang
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Xing Li
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Ping Han
- Department of Respiratory and Critical Care Medicine, Linyi
People’s Hospital, Linyi, China
| | - Miao Guo
- Department of Geriatrics, Linyi People’s Hospital, Linyi,
China
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Caliskan T, Turkoglu O, Canoglu K, Ayten O, Saylan B, Okutan O, Kartaloglu Z. The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism. Medeni Med J 2021; 36:30-35. [PMID: 33828887 PMCID: PMC8020190 DOI: 10.5222/mmj.2021.43066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/27/2021] [Indexed: 12/11/2022] Open
Abstract
Objective This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE). Method We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT. Results The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03). Conclusion There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.
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Affiliation(s)
- Tayfun Caliskan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Ozlem Turkoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | - Kadir Canoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Omer Ayten
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Bengu Saylan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Oguzhan Okutan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Zafer Kartaloglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
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Wang D, Yang F, Zhu X, Cui S, Dong S, Zhang Z, Zhang Y. CTPA pulmonary artery distensibility in assessment of severity of acute pulmonary embolism and right ventricular function. Medicine (Baltimore) 2021; 100:e24356. [PMID: 33546070 PMCID: PMC7837935 DOI: 10.1097/md.0000000000024356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/22/2020] [Indexed: 12/03/2022] Open
Abstract
To investigate the characteristics of pulmonary artery distensibility (PAD) in patients with acute pulmonary embolism (APE) and to assess the correlation of PAD with APE severity and right ventricular function. A total of 33 patients who underwent retrospective electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) with a definite diagnosis of APE were included in the study. According to APE severity, the patients were divided into severe (SPE) and non-severe (NSPE) groups. Data from a control group without APE matching the basic demographics of the APE patients were collected. Pulmonary artery distensibility (PAD) and right ventricular function parameters were compared among the 3 groups, their relationships were investigated, and receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the above parameters for the diagnosis of APE severity. The PAD values of the control, NSPE, and SPE groups were (7.877 ± 2.637) × 10-3 mm/Hg, (6.050 ± 2.011) × 10-3 mm/Hg, (4.321 ± 1.717) × 10-3 mm/Hg, respectively (P < .01). There were statistically significant differences in right ventricular function parameters among the 3 groups (P < .05). The correlation analysis between PAD and right ventricular function parameters showed a weak negative correlation (r = -0.281--0.392). The area under the ROC curve of PAD was 0.743, the critical value was 4.200, and the sensitivity and specificity were 62.5% and 94.1%, respectively. The PAD obtained by retrospective ECG-gated CTPA could accurately evaluate APE severity and right ventricular function. As the severity of APE increases, PAD decreases, which is helpful to identify patients at high risk of APE.
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Affiliation(s)
| | - Fei Yang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Xiaolong Zhu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Shujun Cui
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | - Shanglin Dong
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
| | | | - Yujiao Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, Zhangjiakou
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Bailis N, Lerche M, Meyer HJ, Wienke A, Surov A. Contrast reflux into the inferior vena cava on computer tomographic pulmonary angiography is a predictor of 24-hour and 30-day mortality in patients with acute pulmonary embolism. Acta Radiol 2021; 62:34-41. [PMID: 32241170 DOI: 10.1177/0284185120912506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common disease with a high mortality. Computed tomographic pulmonary angiography (CTPA) represents the current gold standard for the evaluation of patients with suspected PE. PURPOSE To search possible CTPA predictors of 24-h and 30-day mortality in PE. MATERIAL AND METHODS Overall, 224 patients with PE (46.4% women, mean age 64.7 ± 16.7 years) were acquired. CTPA was performed on a multi-slice CT scanner. The following radiological parameters were estimated: thrombotic obstruction index; diameter of the pulmonary trunk (mm); short axis ratio of right ventricle/left ventricle; diameter of the azygos vein (mm); diameter of the superior and inferior vena cava (mm); and reflux of contrast medium into the inferior vena cava (IVC). RESULTS Patients who died within the first 24 h after admission (n = 32, 14.3%) showed a reflux grade 3 into IVC more often than survivors (odds ratio [OR] 7.6, 95% confidence interval [CI] 3.3-17.7; P < 0.001). Other relevant CTPA parameters were diameter of IVC (OR 1.1, 95% CI 1.01-1.21; P = 0.034) and diameter of the pulmonary trunk (OR 0.91, 95% CI 0.82-1.01, P = 0.074), whereas the Mastora score showed nearly no influence (OR 1.01, 95% CI 0.99-1.02, P = 0.406). Furthermore, 61 (27.2%) patients died within the first 30 days after admission. These patients showed a reflux grade 3 into IVC more often than survivors (OR 3.4, 95% CI 1.7-7.0; P = 0.001). Other CTPA parameters, such as diameter of IVC (OR 1.04, 95% CI 0.97-1.12; P = 0.277) and diameter of the pulmonary trunk (OR 0.96, 95% CI 0.89-1.04; P = 0.291), seem to have no relevant influence, whereas Mastora score did (OR 0.99, 95% CI 0.976-0.999, P = 0.045). CONCLUSION Subhepatic contrast reflux into IVC is a strong predictor of 24-h and 30-day mortality in patients with acute PE.
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Affiliation(s)
- Nikolaos Bailis
- Department of Radiology, University of Leipzig, Leipzig, Germany
| | - Marianne Lerche
- Department of Respiratory Medicine, University of Leipzig, Leipzig, Germany
| | - Hans Jonas Meyer
- Department of Radiology, University of Leipzig, Leipzig, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Alexey Surov
- Department of Radiology, University of Leipzig, Leipzig, Germany
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Berghaus TM, Geissenberger F, Konnerth D, Probst M, Kröncke T, Schwarz F. Right-to-left Ventricular Diameter Ratio At Computed Tomographic Pulmonary Angiography in Patients with Acute Pulmonary Embolism and Obstructive Sleep Apnea. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2020; 14:1179548420976430. [PMID: 33354113 PMCID: PMC7734538 DOI: 10.1177/1179548420976430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022]
Abstract
Purpose: Right ventricular (RV) dysfunction in acute pulmonary embolism (PE) is a critical determinant of outcome. Obstructive sleep apnea (OSA) is a common comorbidity of PE and might also affect RV function. Therefore, we sought to investigate RV dysfunction in PE patients in proportion to the severity of OSA by evaluating the right-to-left ventricular (RV/LV) diameter ratio on computed tomographic pulmonary angiography (CTPA). Materials and Methods: 197 PE patients were evaluated for sleep-disordered breathing by portable monitoring and nocturnal polysomnography. RV dilatation was defined as an RV/LV diameter ratio of ⩾ 1.0. Results: RV dilatation was significantly more frequent in OSA patients compared to study participants without OSA (66.4% vs 49.1%, P = .036). Elevated troponin I values, indicating myocardial injury due to acute, PE-related RV strain, were significantly more frequent in OSA patients with an apnea-hypopnea index (AHI) ⩾ 15/h compared to those with an AHI < 15/h (62.1% vs 45.8%, P = .035). However, RV dysfunction documented by the RV/LV diameter ratio on CTPA was not significantly associated with the severity of OSA in multivariable regression analysis. Conclusion: Patients with moderate or severe OSA might compensate acute, PE-related RV strain better, as they are adapted to repetitive right heart pressure overloads during sleep.
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Affiliation(s)
- Thomas M Berghaus
- Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, University of Augsburg, Germany.,Ludwig-Maximilians-University Munich, Germany
| | - Fabian Geissenberger
- Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, University of Augsburg, Germany
| | - Dinah Konnerth
- Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, University of Augsburg, Germany
| | - Michael Probst
- Department of Radiology, University Hospital Augsburg, University of Augsburg, Germany
| | - Thomas Kröncke
- Department of Radiology, University Hospital Augsburg, University of Augsburg, Germany
| | - Florian Schwarz
- Ludwig-Maximilians-University Munich, Germany.,Department of Radiology, University Hospital Augsburg, University of Augsburg, Germany
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Im DJ, Hur J, Han K, Suh YJ, Hong YJ, Lee HJ, Kim YJ, Choi BW. Prognostic Value of Dual-Energy CT-Based Iodine Quantification versus Conventional CT in Acute Pulmonary Embolism: A Propensity-Match Analysis. Korean J Radiol 2020; 21:1095-1103. [PMID: 32691545 PMCID: PMC7371622 DOI: 10.3348/kjr.2019.0645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 12/25/2022] Open
Abstract
Objective The present study aimed to investigate whether quantitative dual-energy computed tomography (DECT) parameters offer an incremental risk stratification benefit over the CT ventricular diameter ratio in patients with acute pulmonary embolism (PE) by using propensity score analysis. Materials and Methods This study was conducted on 480 patients with acute PE who underwent CT pulmonary angiography (CTPA) or DECT pulmonary angiography (DE CT-PA). This propensity-matched study population included 240 patients with acute PE each in the CTPA and DECT groups. Altogether, 260 (54.1%) patients were men, and the mean age was 64.9 years (64.9 ± 13.5 years). The primary endpoint was all-cause death within 30 days. The Cox proportional hazards regression model was used to identify associations between CT parameters and outcomes and to identify potential predictors. Concordance (C) statistics were used to compare the prognoses between the two groups. Results In both CTPA and DECT groups, right to left ventricle diameter ratio ≥ 1 was associated with an increased risk of all-cause death within 30 days (hazard ratio: 3.707, p < 0.001 and 5.573, p < 0.001, respectively). However, C-statistics showed no statistically significant difference between the CTPA and DECT groups for predicting death within 30 days (C-statistics: 0.759 vs. 0.819, p = 0.117). Conclusion Quantitative measurement of lung perfusion defect volume by DECT had no added benefit over CT ventricular diameter ratio for predicting all-cause death within 30 days.
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Affiliation(s)
- Dong Jin Im
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hur
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Joo Suh
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Jin Hong
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jeong Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Challenging anticoagulation cases: A case of acute pulmonary embolism in a patient with chronic thrombocytopenia. Thromb Res 2020; 198:83-85. [PMID: 33302211 DOI: 10.1016/j.thromres.2020.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/06/2020] [Accepted: 11/27/2020] [Indexed: 01/08/2023]
Abstract
We present a case of acute pulmonary embolism in a patient with myelofibrosis and thrombocytopenia. The patient had a history of portal vein thrombosis and had taken warfarin for the past six years. At the time of his pulmonary embolism diagnosis, his INR was 1.5 and platelet count 58 × 109/L. This article discusses how to balance the risk of thrombosis against the risk of bleeding, and reviews the options for pulmonary embolism treatment including transition to low-molecular-weight heparin, direct oral anticoagulants and/or inferior vena cava filters.
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50
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Association between pulmonary arterial obstruction index and right lateral ventricular wall thickness with in-hospital mortality in patients with acute pulmonary embolism. Emerg Radiol 2020; 28:327-331. [PMID: 33184737 DOI: 10.1007/s10140-020-01871-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To retrospectively assess the correlation between pulmonary arterial obstruction index (PAOI) and right lateral ventricular wall thickness with in-hospital mortality in patients with acute pulmonary embolism. METHODS CT angiography (CTA) of 55 consecutive patients (30 males; 25 females; mean age ± SD, 59 ± 11 years) with proven acute pulmonary embolism was investigated. PAOI was determined according to the Qanadli score on CTA. Right ventricular lateral wall thickness was also measured, and patients' in-hospital mortality was recorded. The correlation between PAOI and mortality, right ventricular lateral wall thickness and mortality, and PAOI and right ventricular lateral wall thickness was evaluated. RESULTS PAOI was 23.6 and 10.4 in patients with and without in-hospital mortality, respectively (P < 0.001). Right ventricular lateral wall thickness was 8.7 mm and 7.5 mm in patients with and without in-hospital mortality, respectively (P < 0.001). PAOI more than 21.5 and right ventricular lateral wall thickness more than 8.75 were predictive of in-hospital mortality with a high accuracy. Also, PAOI and right ventricular lateral wall thickness had a significant correlation with each other (P < 0.001; r = 0.695). CONCLUSION PAOI and right ventricular lateral wall thickness on CTA were highly predictive of in-hospital mortality in patients with pulmonary embolism. Right ventricular lateral wall thickness and PAOI had a significant correlation with each other as well.
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