P304 The importance of echocardiographic pulmonary flow notch ratio in the assessment of patients with acute pulmonary embolism

Background

There are several echocardiographic features such as right ventricle dilatation, interventricular septum flattening, McConnel sign and 60/60 sign reflecting the extent and severity of acute pulmonary embolism (APE). In quite a large number of APE patients we can observe a pulmonary flow (PF) profile abnormality in the form of a mid-systolic notch (MSN).

Purpose

To assess the profile of pulmonary Doppler flow in consecutive patients with acute pulmonary embolism and to establish its clinical utility.

Methods

We reviewed pulmonary Doppler flow profiles from 127 consecutive patients (m. age 64 years,72 F) with symptomatic APE managed in our department. APE was confirmed by contrast-enhanced multi detector computed tomography when thromboemboli were visualized at least in segmental pulmonary arteries. Individuals with preexisting pulmonary arterial hypertension were excluded. The pulmonary flow notch ratio (PNR) defined as the time from onset of PF until mid-systolic notch divided by the time from notch to the end of pulmonary ejection was evaluated. The comparison of patients with PNR < 1 (Group 1) and PNR > 1 (Group 2) was performed.

Results

We found the MSN in 50 patients (39.4%). Seventy seven patients had a normal shape of Doppler PF envelope. The presence of MSN was associated with more pronounced echocardiographic signs of right ventricle overload (RVOT diameter 32.4± 5.2 vs 29.1 ±3.3 mm, p < 0.001; TRPG 42.3 ± 14.4 vs 24.8 ±9.5 mmHg, p < 0.0001; RVSP 49.4 ±14.9 vs 31.2 ±10.6 mmHg, p < 0.0001; TAPSE 20.3± 4.1 vs 23.4 ±4.0 mm, p < 0.001; PF Acceleration Time 64.5 ±13.7 vs 109.8 ±24.6 ms, p < 0.001, and a presence of septal flattening). Obviously, patients with MSN presented more proximal location of thrombi in comparison to those with symmetrical shape of PF envelope (in MPA 18% vs 5.2%, p = 0.038 and in both LPA + RPA 22% vs 9%, p = 0.08, respectively). The PNR < 1 was found in 35 (70%) of 50 patients with MSN (Group 1). In these patients thrombi were located more proximally than in patients with PNR > 1 (Group 2), and angio-CT confirm anatomically massive PE. A percentage of patients with thrombi in both, left and right pulmonary arteries, in both lobar pulmonary arteries and lobar+ segmental arteries was higher in Group 1 (PNR < 1) than in Group 2 (PNR > 1): LPA + RPA: 28.6 vs 6.7%, lobar L and R: 57 vs 26.6%, lobar + segmental: 31 vs 20%. A number of patients with thrombi in the MPA was similar in both groups.

Conclusion

A noninvasive pulmonary flow notch ratio (PNR) may be useful for indicating APE patients with more extensive disease and proximal location of thrombi, at least in lobar pulmonary arteries.

D-dimer levels enhance the discriminatory capacity of bleeding risk scores for predicting in-hospital bleeding events in acute pulmonary embolism

INTRODUCTION

Bleeding is a major complication of anticoagulation in acute pulmonary embolism (APE) while estimating individual bleeding risk remains challenging. Elevated D-dimer levels (DD) have been shown to predict bleeding events.

OBJECTIVES

(1) direct comparison of the capacity of bleeding risk prediction scores (VTE-BLEED, RIETE, HAS-BLED, HEMORR₂HAGES) to prognosticate in-hospital bleeding events in the acute phase of APE in a real-life population of APE patients;(2) augmentation of the discriminative capacity of fore mentioned scores with DD.

MATERIALS

Post-hoc analysis of a prospective observational study. DD levels were measured using the VIDAS D-dimer Exclusion test. Receiver operating characteristic curves, areas under the curve (AUC) for bleeding prediction were calculated for scores and DD. Bleeding scores+DD were compared using an established index quantifying the reclassification of patients (net reclassification index, NRI).

RESULTS

310 APE patients were included. 35(11.3%) bleeding events occurred (hematomas, GI, urinary tract, retroperitoneal, uterine, CNS, respiratory tract): 17 major (MB) and 18 clinically-relevant non-major bleedings (CRNMB), none were fatal. All scores had satisfactory AUCs (0.754-0.767), except HAS-BLED (AUC = 0.512; 0.455-0.569). DD were higher in patients with bleeding events (29,911 ng/ml vs. 4805 ng/ml, p = .031), AUC 0.621(0.520-0.721), p = .02. DD = 5750 ng/ml was characterized by OR = 2.3(95%CI 1.05-5.0) for all bleeding events. Adding DD improved the discriminatory capacity of tested scores in the non-high risk of bleeding category, NRI 0.07-03.

CONCLUSIONS

Of the tested scores RIETE, HEMORR₂HAGES, VTE-BLEED performed best at identifying APE patients at risk of in-hospital bleeding complications. DD levels may predict in-hospital bleeding events and may improve identifying patients classified as non-high risk who experience bleeding complications.

Balloon pulmonary angioplasty - efficient therapy of chronic thromboembolic pulmonary hypertension in the patient with advanced sarcoidosis - a case report

BACKGROUND

Approximately a quarter of patients with advanced sarcoidosis develop pulmonary hypertension (PH), which affects their prognosis. We report unusual case of confirmed chronic thromboembolic pulmonary hypertension (CTEPH) in a patient with stage IV sarcoidosis successfully treated with balloon pulmonary angioplasty (BPA).

CASE PRESENTATION

A 65 years old male with a history of colitis ulcerosa, and pulmonary sarcoidosis diagnosed in 10 years before, on long term oral steroids, with a history of deep vein thrombosis and acute pulmonary embolism chronically anticoagulated was referred to our center due to severe dyspnea. On admission he presented WHO functional class IV, mean pulmonary artery pressure (mPAP) in right heart catheterization (RHC) was elevated to 54 mmHg. Diagnosis of CTEPH was definitely confirmed with typical V/Q scan, and with selective pulmonary angiography (PAG) completes by intravascular imagining (intravascular ultrasound, optical coherent tomography). The patient was deemed inoperable by CTEPH team and two sessions of BPA with multimodal approach resulted in significant clinical and haemodynamical improvement to WHO class II and mPAP decrease to 27 mmHg.

CONCLUSIONS

Balloon pulmonary angioplasty, rapidly developing method of treatment of inoperable CTEPH patients, is also extremely useful therapeutic tool in complex PH patients.

d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

Management of high risk pulmonary embolism - a single center experience

BACKGROUND AND AIM

Patients with acute pulmonary embolism (APE) associated with hemodynamic instability, i.e. high-risk APE (HR-APE), are at risk for early mortality and require urgent reperfusion therapy with thrombolysis or embolectomy. However, a considerable proportion of HR-APE subjects is not reperfused but only anticoagulated due to high bleeding risk. The aim of the present study was to assess the management of HR-APE in a single large-volume referral center.

METHODS

A single-center retrospective study of 32 HR-APE subjects identified among 823 consecutive patients hospitalized for symptomatic APE.

RESULTS

Out of 32 subjects with HR-APE (19 women, age 69 ± 19 years), 20 patients were unstable at admission and 12 subsequently deteriorated despite on-going anticoagulation. Thrombolysis was applied in 20 (62.5%) of HR-APE subjects, limited mainly by classical contraindications in the remainder. Percutaneous pulmonary embolectomy was performed in 4 patients. In-hospital PE-related mortality tended to be higher, albeit insignificantly, in the patients who developed hemodynamic collapse during the hospital course compared to those unstable at admission (67% vs. 40%, p = 0.14). Also, survival was slightly better in 22 patients treated with thrombolysis or percutaneous embolectomy in comparison to 10 subjects who received only anticoagulation (54% vs. 40%, p = 0.2). Major non-fatal bleedings occurred in 7 of 20 patients receiving thrombolysis (35%) and in 2 (17%) of the remaining non-thrombolysed 12 HR-APE subjects.

CONCLUSIONS

Hemodynamically instability, corresponding to the definition of HR-APE, affects about 4% of patients with APE, developing during the hospital course in approximately one-third of HR-APE subjects. As almost 40% of patients with HR-APE do not receive thrombolytic therapy for fear of bleeding, urgent percutaneous catheter-assisted embolectomy may increase the percentage of patients with HR-APE undergoing reperfusion therapy. Further studies are warranted for a proper identification of initially stable intermediate-risk APE subjects at risk of hemodynamic collapse despite appropriate anticoagulation.