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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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2
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de Jong CMM, van den Hout WB, van Dijk CE, Heim N, van Dam LF, Dronkers CEA, Gautam G, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, van Mens TE, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis. Thromb Haemost 2023. [PMID: 37984402 DOI: 10.1055/a-2213-9230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison. OBJECTIVES To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients. METHODS Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared. RESULTS All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. CONCLUSION One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences - Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Noor Heim
- National Health Care Institute, The Netherlands
| | - Lisette F van Dam
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Charlotte E A Dronkers
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gargi Gautam
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Gralum, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Anders von Heijne
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marcel M C Hovens
- Department of Vascular Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stan Kolman
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel A van de Ree
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | | | | | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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3
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Kaptein FHJ, Kroft LJM, van Dam LF, Stöger JL, Ninaber MK, Huisman MV, Klok FA. Impact of pulmonary infarction in pulmonary embolism on presentation and outcomes. Thromb Res 2023; 226:51-55. [PMID: 37121011 DOI: 10.1016/j.thromres.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/10/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Pulmonary infarction (PI) is relatively common in pulmonary embolism (PE). The association between PI and persistent symptoms or adverse events is largely unknown. AIM To evaluate the predictive value of radiological PI signs at acute PE diagnosis on 3-month outcomes. METHODS We studied a convenience cohort with computed tomography pulmonary angiography (CTPA)-confirmed PE for whom extensive 3-month follow-up data were available. The CTPAs were re-evaluated for signs of suspected PI. Associations with presenting symptoms, adverse events (recurrent thrombosis, PE-related readmission and mortality) and self-reported persistent symptoms (dyspnea, pain and post-PE functional impairment) at 3-month follow-up were investigated using univariate Cox regression analysis. RESULTS At re-evaluation of the CTPAs, 57 of 99 patients (58 %) had suspected PI, comprising a median of 1 % (IQR 1-3) of total lung parenchyma. Patients with suspected PI more often presented with hemoptysis (11 % vs. 0 %) and pleural pain (OR 2.7, 95%CI 1.2-6.2), and with more proximal PE on CTPA (OR 1.6, 95%CI 1.1-2.4) than patients without suspected PI. There was no association with adverse events, persistent dyspnea or pain at 3-month follow-up, but signs of PI predicted more functional impairment (OR 3.03, 95%CI 1.01-9.13). Sensitivity analysis with the largest infarctions (upper tertile of infarction volume) yielded similar results. CONCLUSIONS PE patients radiologically suspected of PI had a different clinical presentation than patients without those signs and reported more functional limitations after 3 months of follow-up, a finding that could guide patient counselling.
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Affiliation(s)
- F H J Kaptein
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - L F van Dam
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M K Ninaber
- Department of Pulmonology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands.
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Zhai Z, Boon GJAM, Staring M, van Dam LF, Kroft LJM, Hernández Girón I, Ninaber MK, Bogaard HJ, Meijboom LJ, Vonk Noordegraaf A, Huisman MV, Klok FA, Stoel BC. Automated quantification of the pulmonary vasculature in pulmonary embolism and chronic thromboembolic pulmonary hypertension. Pulm Circ 2023; 13:e12223. [PMID: 37128354 PMCID: PMC10148047 DOI: 10.1002/pul2.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
The shape and distribution of vascular lesions in pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH) are different. We investigated whether automated quantification of pulmonary vascular morphology and densitometry in arteries and veins imaged by computed tomographic pulmonary angiography (CTPA) could distinguish PE from CTEPH. We analyzed CTPA images from a cohort of 16 PE patients, 6 CTEPH patients, and 15 controls. Pulmonary vessels were extracted with a graph-cut method, and separated into arteries and veins using deep-learning classification. Vascular morphology was quantified by the slope (α) and intercept (β) of the vessel radii distribution. To quantify lung perfusion defects, the median pulmonary vascular density was calculated. By combining these measurements with densities measured in parenchymal areas, pulmonary trunk, and descending aorta, a static perfusion curve was constructed. All separate quantifications were compared between the three groups. No vascular morphology differences were detected in contrast to vascular density values. The median vascular density (interquartile range) was -567 (113), -452 (95), and -470 (323) HU, for the control, PE, and CTEPH group. The static perfusion curves showed different patterns between groups, with a statistically significant difference in aorta-pulmonary trunk gradient between the PE and CTEPH groups (p = 0.008). In this proof of concept study, not vasculature morphology but densities differentiated between patients of three groups. Further technical improvements are needed to allow for accurate differentiation between PE and CTEPH, which in this study was only possible statistically by measuring the density gradient between aorta and pulmonary trunk.
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Affiliation(s)
- Zhiwei Zhai
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gudula J. A. M. Boon
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Marius Staring
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Lisette F. van Dam
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Irene Hernández Girón
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Maarten K. Ninaber
- Department of PulmonologyLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Menno V. Huisman
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Berend C. Stoel
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
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de Jong CMM, Visser C, Bemelmans RHH, Boersma WG, van den Borst B, Burggraaf JLI, Cannegieter SC, Ten Cate-Hoek AJ, Croles FN, Faber HJ, Faber LM, Hellemons ME, Hessels LM, Huisman MV, Kamphuisen PW, Koster SCE, Kroft LJM, van der Lee I, Leentjens J, Meijer K, Ninaber MK, Sondermeijer BM, Stads S, Vonk Noordegraaf A, Winckers K, Kruip MJHA, Klok FA. Chronic thromboembolic pulmonary hypertension and clot resolution after COVID-19-associated pulmonary embolism. Eur Respir J 2023; 61:13993003.00171-2023. [PMID: 37080574 PMCID: PMC10116061 DOI: 10.1183/13993003.00171-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/20/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Chantal Visser
- Department of Haematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Wim G Boersma
- Department of Pulmonology, North West Hospital Alkmaar, Alkmaar, The Netherlands
| | - Bram van den Borst
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Louise I Burggraaf
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arina J Ten Cate-Hoek
- Thrombosis Expertise Center Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - F Nanne Croles
- Department of Internal Medicine, Hospital St. Jansdal, Harderwijk, The Netherlands
| | - Harald J Faber
- Department of Intensive Care, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Merel E Hellemons
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lisa M Hessels
- Department of Pulmonology, North West Hospital Alkmaar, Alkmaar, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter W Kamphuisen
- Department of Internal Medicine, Tergooi Hospital, Hilversum, The Netherlands
- Department of Vascular Medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ivo van der Lee
- Department of Pulmonology, Spaarne Hospital, Haarlem, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Susanne Stads
- Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Kristien Winckers
- Thrombosis Expertise Center Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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6
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Rijnberg FM, van ‘t Hul LC, Hazekamp MG, van den Boogaard PJ, Juffermans JF, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, le Cessie S, Jongbloed MRM, Westenberg JJM, Roest AAW, Wentzel JJ. Haemodynamic performance of 16-20-mm extracardiac Goretex conduits in adolescent Fontan patients at rest and during simulated exercise. Eur J Cardiothorac Surg 2022; 63:6808623. [PMID: 36342204 PMCID: PMC9972516 DOI: 10.1093/ejcts/ezac522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/03/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To date, it is not known if 16-20-mm extracardiac conduits are outgrown during somatic growth from childhood to adolescence. This study aims to determine total cavopulmonary connection (TCPC) haemodynamics in adolescent Fontan patients at rest and during simulated exercise and to assess the relationship between conduit size and haemodynamics. METHODS Patient-specific, magnetic resonance imaging-based computational fluid dynamic models of the TCPC were performed in 51 extracardiac Fontan patients with 16-20-mm conduits. Power loss, pressure gradient and normalized resistance were quantified in rest and during simulated exercise. The cross-sectional area (CSA) (mean and minimum) of the vessels of the TCPC was determined and normalized for flow rate (mm2/l/min). Peak (predicted) oxygen uptake was assessed. RESULTS The median age was 16.2 years (Q1-Q3 14.0-18.2). The normalized mean conduit CSA was 35-73% smaller compared to the inferior and superior vena cava, hepatic veins and left/right pulmonary artery (all P < 0.001). The median TCPC pressure gradient was 0.7 mmHg (Q1-Q3 0.5-0.8) and 2.0 (Q1-Q3 1.4-2.6) during rest and simulated exercise, respectively. A moderate-strong inverse non-linear relationship was present between normalized mean conduit CSA and TCPC haemodynamics in rest and exercise. TCPC pressure gradients of ≥1.0 at rest and ≥3.0 mmHg during simulated exercise were observed in patients with a conduit CSA ≤ 45 mm2/l/min and favourable haemodynamics (<1 mmHg during both rest and exercise) in conduits ≥125 mm2/l/min. Normalized TCPC resistance correlated with (predicted) peak oxygen uptake. CONCLUSIONS Extracardiac conduits of 16-20 mm have become relatively undersized in most adolescent Fontan patients leading to suboptimal haemodynamics.
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Affiliation(s)
- Friso M Rijnberg
- Corresponding author. Department of Cardiothoracic surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands, Telephone number:+31715262348 (F.M. Rijnberg)
| | - Luca C van ‘t Hul
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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7
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Rijnberg FM, Westenberg JJM, van Assen HC, Juffermans JF, Kroft LJM, van den Boogaard PJ, Terol Espinosa de Los Monteros C, Warmerdam EG, Leiner T, Grotenhuis HB, Jongbloed MRM, Hazekamp MG, Roest AAW, Lamb HJ. 4D flow cardiovascular magnetic resonance derived energetics in the Fontan circulation correlate with exercise capacity and CMR-derived liver fibrosis/congestion. J Cardiovasc Magn Reson 2022; 24:21. [PMID: 35346249 PMCID: PMC8962091 DOI: 10.1186/s12968-022-00854-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIM This study explores the relationship between in vivo 4D flow cardiovascular magnetic resonance (CMR) derived blood flow energetics in the total cavopulmonary connection (TCPC), exercise capacity and CMR-derived liver fibrosis/congestion. BACKGROUND The Fontan circulation, in which both caval veins are directly connected with the pulmonary arteries (i.e. the TCPC) is the palliative approach for single ventricle patients. Blood flow efficiency in the TCPC has been associated with exercise capacity and liver fibrosis using computational fluid dynamic modelling. 4D flow CMR allows for assessment of in vivo blood flow energetics, including kinetic energy (KE) and viscous energy loss rate (EL). METHODS Fontan patients were prospectively evaluated between 2018 and 2021 using a comprehensive cardiovascular and liver CMR protocol, including 4D flow imaging of the TCPC. Peak oxygen consumption (VO2) was determined using cardiopulmonary exercise testing (CPET). Iron-corrected whole liver T1 (cT1) mapping was performed as a marker of liver fibrosis/congestion. KE and EL in the TCPC were computed from 4D flow CMR and normalized for inflow. Furthermore, blood flow energetics were compared between standardized segments of the TCPC. RESULTS Sixty-two Fontan patients were included (53% male, 17.3 ± 5.1 years). Maximal effort CPET was obtained in 50 patients (peak VO2 27.1 ± 6.2 ml/kg/min, 56 ± 12% of predicted). Both KE and EL in the entire TCPC (n = 28) were significantly correlated with cT1 (r = 0.50, p = 0.006 and r = 0.39, p = 0.04, respectively), peak VO2 (r = - 0.61, p = 0.003 and r = - 0.54, p = 0.009, respectively) and % predicted peak VO2 (r = - 0.44, p = 0.04 and r = - 0.46, p = 0.03, respectively). Segmental analysis indicated that the most adverse flow energetics were found in the Fontan tunnel and left pulmonary artery. CONCLUSIONS Adverse 4D flow CMR derived KE and EL in the TCPC correlate with decreased exercise capacity and increased levels of liver fibrosis/congestion. 4D flow CMR is promising as a non-invasive screening tool for identification of patients with adverse TCPC flow efficiency.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Tim Leiner
- Department of Radiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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8
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Zhao Q, Nooren SJL, Zijlstra LE, Westenberg JJM, Kroft LJM, Jukema JW, Berkhout-Byrne NC, Rabelink TJ, van Zonneveld AJ, van Buren M, Mooijaart SP, Bijkerk R. Circulating miRNAs and Vascular Injury Markers Associate with Cardiovascular Function in Older Patients Reaching End-Stage Kidney Disease. Noncoding RNA 2022; 8:ncrna8010002. [PMID: 35076541 PMCID: PMC8788543 DOI: 10.3390/ncrna8010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
The prevalence of end-stage kidney disease (ESKD) is rapidly increasing and mostly occurring in patients aged 65 years or older. The main cause of death in these patients is cardiovascular disease (CVD). Novel markers of vascular integrity may thus be of clinical value for identifying patients at high risk for CVD. Here we associated the levels of selected circulating angiogenic miRNAs, angiopoietin-2 (Ang-2) and asymmetric dimethylarginine (ADMA) with cardiovascular structure and function (as determined by cardiovascular MRI) in 67 older patients reaching ESKD that were included from ‘The Cognitive decline in Older Patients with End stage renal disease’ (COPE) prospective, multicentered cohort study. We first determined the association between the vascular injury markers and specific heart conditions and observed that ESKD patients with coronary heart disease have significantly higher levels of circulating ADMA and miR-27a. Moreover, circulating levels of miR-27a were higher in patients with atrial fibrillation. In addition, the circulating levels of the vascular injury markers were associated with measures of cardiovascular structure and function obtained from cardiovascular MRI: pulse wave velocity (PWV), ejection fraction (EF) and cardiac index (CI). We found Ang-2 and miR-27a to be strongly correlated to the PWV, while Ang-2 also associated with ejection fraction. Finally, we observed that in contrast to miR-27a, Ang-2 was not associated with a vascular cause of the primary kidney disease, suggesting Ang-2 may be an ESKD-specific marker of vascular injury. Taken together, among older patients with ESKD, aberrant levels of vascular injury markers (miR-27a, Ang-2 and ADMA) associated with impaired cardiovascular function. These markers may serve to identify individuals at higher risk of CVD, as well as give insight into the underlying (vascular) pathophysiology.
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Affiliation(s)
- Qiao Zhao
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Sabine J. L. Nooren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Laurien E. Zijlstra
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (L.E.Z.); (J.W.J.)
| | - Jos J. M. Westenberg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (J.J.M.W.); (L.J.M.K.)
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (J.J.M.W.); (L.J.M.K.)
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (L.E.Z.); (J.W.J.)
- Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Noeleen C. Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
| | - Ton J. Rabelink
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Department of Nephrology, HAGA Hospital, 2545 AA The Hague, The Netherlands
| | - Simon P. Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands;
| | - Roel Bijkerk
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Correspondence: ; Tel.: +31-(0)71-526-8138; Fax: +31-(0)71-526-6868
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9
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Rijnberg FM, van der Woude SFS, Hazekamp MG, van den Boogaard PJ, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, Karim T, Jongbloed MRM, Westenberg JJM, Wentzel JJ, Roest AAW. Extracardiac conduit adequacy along the respiratory cycle in adolescent Fontan patients. Eur J Cardiothorac Surg 2021; 62:6423130. [PMID: 34747442 PMCID: PMC9257669 DOI: 10.1093/ejcts/ezab478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/12/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Tawab Karim
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
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10
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Boon GJAM, Jairam PM, Groot GMC, van Rooden CJ, Ende-Verhaar YM, Beenen LFM, Kroft LJM, Bogaard HJ, Huisman MV, Symersky P, Vonk Noordegraaf A, Meijboom LJ, Klok FA. Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 2021; 93:64-70. [PMID: 34294517 DOI: 10.1016/j.ejim.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Expert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. OBJECTIVES To evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. METHODS Original reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. RESULTS Signs of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts' consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). CONCLUSIONS Concomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Pushpa M Jairam
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerie M C Groot
- Department of Radiology, Medical Center Gelderse Vallei, Ede, the Netherlands
| | | | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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11
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van Vliet R, Kroft LJM, Hazekamp MG, Roest AAW, van der Palen RLF. Pulmonary ductal coarctation: An entity associated with congenital heart defects involving the right ventricle outflow tract. J Card Surg 2021; 36:4754-4755. [PMID: 34637184 PMCID: PMC9291456 DOI: 10.1111/jocs.16067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/27/2022]
Abstract
We present a case of a prematurely born 2‐month‐old girl with a double outlet right ventricle with pulmonary atresia and a left pulmonary artery coarctation arising after ductal closure. The case highlights the importance of knowledge and identification of such an anomaly in patients with congenital heart malformations with severe pulmonary stenosis to atresia.
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Affiliation(s)
- Relin van Vliet
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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12
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Stals MAM, Kaptein FHJ, Bemelmans RHH, van Bemmel T, Boukema IC, Braeken DCW, Braken SJE, Bresser C, Cate HT, Deenstra DD, Dooren YPAV, Faber LM, Grootenboers MJJH, Haan LRD, Haazer C, Sol AID, Kelliher S, Koster T, Kroft LJM, Meijer RI, Pals F, van Thiel ERE, Westerweel PE, Wolde MT, Klok FA, Huisman MV. Ruling out Pulmonary Embolism in Patients with (Suspected) COVID-19-A Prospective Cohort Study. TH Open 2021; 5:e387-e399. [PMID: 34541450 PMCID: PMC8443402 DOI: 10.1055/s-0041-1735155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 01/08/2023] Open
Abstract
Background
Diagnostic strategies for suspected pulmonary embolism (PE) have not been prospectively evaluated in COVID-19 patients.
Methods
Prospective, multicenter, outcome study in 707 patients with both (suspected) COVID-19 and suspected PE in 14 hospitals. Patients on chronic anticoagulant therapy were excluded. Informed consent was obtained by opt-out approach. Patients were managed by validated diagnostic strategies for suspected PE. We evaluated the safety (3-month failure rate) and efficiency (number of computed tomography pulmonary angiographies [CTPAs] avoided) of the applied strategies.
Results
Overall PE prevalence was 28%. YEARS was applied in 36%, Wells rule in 4.2%, and “CTPA only” in 52%; 7.4% was not tested because of hemodynamic or respiratory instability. Within YEARS, PE was considered excluded without CTPA in 29%, of which one patient developed nonfatal PE during follow-up (failure rate 1.4%, 95% CI 0.04–7.8). One-hundred seventeen patients (46%) managed according to YEARS had a negative CTPA, of whom 10 were diagnosed with nonfatal venous thromboembolism (VTE) during follow-up (failure rate 8.8%, 95% CI 4.3–16). In patients managed by CTPA only, 66% had an initial negative CTPA, of whom eight patients were diagnosed with a nonfatal VTE during follow-up (failure rate 3.6%, 95% CI 1.6–7.0).
Conclusion
Our results underline the applicability of YEARS in (suspected) COVID-19 patients with suspected PE. CTPA could be avoided in 29% of patients managed by YEARS, with a low failure rate. The failure rate after a negative CTPA, used as a sole test or within YEARS, was non-negligible and reflects the high thrombotic risk in these patients, warranting ongoing vigilance.
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Fleur H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, Gelderland, The Netherlands
| | - Inge C Boukema
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Dionne C W Braeken
- Thrombosis Expertise Center, Maastricht University Medical Center, Maastricht, Limburg, the Netherlands
| | - Sander J E Braken
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Carlinda Bresser
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expertise Center, Maastricht University Medical Centre + , Maastricht, Limburg, The Netherlands
| | - Duco D Deenstra
- Department of Pulmonology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Yordi P A van Dooren
- Department of Pulmonology, Groene Hart Hospital, Gouda, Zuid-Holland, The Netherlands
| | - Laura M Faber
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, The Netherlands
| | | | - Lianne R de Haan
- Department of Internal Medicine, Flevo Hospital, Almere, Flevoland, The Netherlands
| | - Carolien Haazer
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, Zuid-Holland, The Netherlands
| | - Antonio Iglesias Del Sol
- Department of Internal Medicine, Alrijne Hospital Location Leiderdorp, Leiderdorp, Zuid-Holland, The Netherlands
| | - Sarah Kelliher
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Hospital, Gouda, Zuid-Holland, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick I Meijer
- Department of Internal Medicine Amsterdam UMC Locatie VUMC, Amsterdam, Noord-Holland, The Netherlands
| | - Fleur Pals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Eric R E van Thiel
- Department of Pulmonology, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, Flevoland, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
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13
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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14
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van Dam LF, Dronkers CEA, Gautam G, Eckerbom Å, Ghanima W, Gleditsch J, van Haren GR, von Heijne A, Huisman MV, Stöger JL, Westerlund E, Kroft LJM, Klok FA. Detection of upper extremity deep vein thrombosis by magnetic resonance non-contrast thrombus imaging. J Thromb Haemost 2021; 19:1973-1980. [PMID: 34018662 PMCID: PMC8361740 DOI: 10.1111/jth.15394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Compression ultrasonography (CUS) is the first-line imaging test for diagnosing upper extremity deep vein thrombosis (UEDVT), but often yields inconclusive test results. Contrast venography is still considered the diagnostic standard but is an invasive technique. OBJECTIVES We aimed to determine the diagnostic accuracy of magnetic resonance noncontrast thrombus imaging (MR-NCTI) for the diagnosis of UEDVT. METHODS In this international multicenter diagnostic study, we prospectively included patients with clinically suspected UEDVT who were managed according to a diagnostic algorithm that included a clinical decision rule (CDR), D-dimer test, and diagnostic imaging. UEDVT was confirmed by CUS or (computed tomography [CT]) venography. UEDVT was excluded by (1) an unlikely CDR and normal D-dimer, (2) a normal serial CUS or (3) a normal (CT) venography. Within 48 h after the final diagnosis was established, patients underwent MR-NCTI. MR-NCTI images were assessed post hoc by two independent radiologists unaware of the presence or absence of UEDVT. The sensitivity, specificity, and interobserver agreement of MR-NCTI for UEDVT were determined. RESULTS Magnetic resonance noncontrast thrombus imaging demonstrated UEDVT in 28 of 30 patients with UEDVT and was normal in all 30 patients where UEDVT was ruled out, yielding a sensitivity of 93% (95% CI 78-99) and specificity of 100% (95% CI 88-100). The interobserver agreement of MR-NCTI had a kappa value of 0.83 (95% CI 0.69-0.97). CONCLUSIONS Magnetic resonance noncontrast thrombus imaging is an accurate and reproducible method for diagnosing UEDVT. Clinical outcome studies should determine whether MR-NCTI can replace venography as the second-line imaging test in case of inconclusive CUS.
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Affiliation(s)
- Lisette F. van Dam
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Charlotte E. A. Dronkers
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineHaaglanden Medical CenterThe HagueThe Netherlands
| | - Gargi Gautam
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Åsa Eckerbom
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Waleed Ghanima
- Internal Medicine ClinicØstfold Hospital TrustØstfoldNorway
- Department of HaematologyOslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | | | - Guido R. van Haren
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Anders von Heijne
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - J. Lauran Stöger
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Eli Westerlund
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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15
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van der Palen RLF, Juffermans JF, Kroft LJM, Hazekamp MG, Lamb HJ, Blom NA, Roest AAW, Westenberg JJM. Wall shear stress in the thoracic aorta at rest and with dobutamine stress after arterial switch operation. Eur J Cardiothorac Surg 2021; 59:814-822. [PMID: 33382414 PMCID: PMC8083947 DOI: 10.1093/ejcts/ezaa392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Progressive root dilatation is an important complication in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) that may be caused by altered flow dynamics. Aortic wall shear stress (WSS) distribution at rest and under dobutamine stress (DS) conditions using 4D flow magnetic resonance imaging were investigated in relation to thoracic aorta geometry. METHODS 4D flow magnetic resonance imaging was performed in 16 adolescent TGA patients after ASO (rest and DS condition) and in 10 healthy controls (rest). The primary outcome measure was the WSS distribution along the aortic segments and the WSS change with DS in TGA patients. Based on the results, we secondary zoomed in on factors [aortic geometry and left ventricular (LV) function parameters] that might relate to these WSS distribution differences. Aortic diameters, arch angle, LV function parameters (stroke volume, LV ejection fraction, cardiac output) and peak systolic aortic WSS were obtained. RESULTS TGA patients had significantly larger neoaortic root and smaller mid-ascending aorta (AAo) dimensions and aortic arch angle. At rest, patients had significantly higher WSS in the entire thoracic aorta, except for the dilated root. High WSS levels beyond the proximal AAo were associated with the diameter decrease from the root to the mid-AAo (correlation coefficient r = 0.54–0.59, P = 0.022–0.031), not associated with the aortic arch angle. During DS, WSS increased in all aortic segments (P < 0.001), most pronounced in the AAo segments. The increase in LV ejection fraction, stroke volume and cardiac output as a result of DS showed a moderate linear relationship with the WSS increase in the distal AAo (correlation coefficient r = 0.54–0.57, P = 0.002–0.038). CONCLUSIONS Increased aortic WSS was observed in TGA patients after ASO, related to the ASO-specific geometry, which increased with DS. Stress-enhanced elevated WSS may play a role in neoaortic root dilatation and anterior aortic wall thinning of the distal AAo.
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Affiliation(s)
- Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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16
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Braams NJ, Boon GJAM, de Man FS, van Es J, den Exter PL, Kroft LJM, Beenen LFM, Huisman MV, Nossent EJ, Boonstra A, Vonk Noordegraaf A, Ruigrok D, Klok FA, Bogaard HJ, Meijboom LJ. Evolution of CT findings after anticoagulant treatment for acute pulmonary embolism in patients with and without an ultimate diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 58:13993003.00699-2021. [PMID: 34112733 DOI: 10.1183/13993003.00699-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of computed tomography pulmonary angiography (CTPA) findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. METHODS We analysed CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further subclassified as 1) central thrombus, 2) total thrombotic occlusion, 3) mural thrombus, 4) web or 5) tapered pulmonary artery. RESULTS Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. CONCLUSIONS Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnoea after anticoagulant treatment for acute PE.
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Affiliation(s)
- Natalia J Braams
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gudula J A M Boon
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frances S de Man
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Dept of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ludo F M Beenen
- Dept of Radiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dieuwertje Ruigrok
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands .,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
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17
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Kaptein FHJ, Kroft LJM, Hammerschlag G, Ninaber MK, Bauer MP, Huisman MV, Klok FA. Pulmonary infarction in acute pulmonary embolism. Thromb Res 2021; 202:162-169. [PMID: 33862471 DOI: 10.1016/j.thromres.2021.03.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 01/10/2023]
Abstract
Pulmonary infarction results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage and ultimately necrosis of the lung parenchyma. It is most commonly caused by acute pulmonary embolism (PE), with a reported incidence of around 30%. Following an occlusion of the pulmonary artery, the bronchial arteries are recruited as primary source of perfusion of the pulmonary capillaries. The relatively higher blood pressure in the bronchial circulation causes an increase in the capillary blood flow, leading to extravasation of erythrocytes (i.e. alveolar hemorrhage). If this hemorrhage cannot be resorbed, it results in tissue necrosis and infarction. Different definitions of pulmonary infarction are used in literature (clinical, radiological and histological), although the diagnosis is nowadays mostly based on radiological characteristics. Notably, the infarcted area is only replaced by a fibrotic scar over a period of months. Hence and formally, the diagnosis of pulmonary infarction cannot be confirmed upon diagnosis of acute PE. Little is known of the impact and relevance of pulmonary infarction in acute PE, and whether specific management strategies should be applied to prevent and/or treat complications such as pain, pneumonia or post-PE syndrome. In this review we will summarize current knowledge on the pathophysiology, epidemiology, diagnosis and prognosis of pulmonary infarction in the setting of acute PE. We highlight the need for dedicated studies to overcome the current knowledge gaps.
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Affiliation(s)
- F H J Kaptein
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - G Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Australia
| | - M K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - M P Bauer
- Department of Medicine - Acute Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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18
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van Dam LF, Boon GDJAM, Kroft LJM, Huisman MV, Klok FEA. [Diagnosis of recurrent venous thromboembolism]. Ned Tijdschr Geneeskd 2021; 165:D5550. [PMID: 33793129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A correct diagnosis of recurrent venous thromboembolism (VTE) is essential as patients diagnosed with a recurrence are mostly treated with lifelong anticoagulant treatment. However, the diagnosis of recurrent VTE is complex as routine diagnostic tests for suspected VTE are less accurate in patients without a prior VTE. Clinical decision rules (CDR) and D-dimer tests have a lower specificity in suspected recurrent VTE, leading to an increase in required diagnostic imaging tests. In contrast to suspected recurrent pulmonary embolism (PE), the safety of a CDR and D-dimer test in excluding recurrent deep vein thrombosis (DVT) is debated. A CDR in combination with D-dimer testing followed by computed tomography pulmonary angiography is the preferred diagnostic management for suspected recurrent PE. In suspected recurrent DVT, compression ultrasonography is the imaging technique of choice and in case of a suspected recurrent ipsilateral DVT and an inconclusive ultrasonography, magnetic resonance direct thrombus imaging is decisive.
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19
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van der Ven JPG, Bossers SSM, van den Bosch E, Dam N, Kuipers IM, van Iperen GG, Kroft LJM, Kapusta L, Ten Harkel ADJ, Helbing WA. Dobutamine stress testing for the evaluation of atrial and diastolic ventricular function in Fontan patients. Open Heart 2021; 8:openhrt-2020-001487. [PMID: 33712485 PMCID: PMC7959216 DOI: 10.1136/openhrt-2020-001487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 11/22/2022] Open
Abstract
Objective To assess the atrial and ventricular diastolic function response to dobutamine stress in Fontan patients, and to relate these measurements to exercise capacity and events during the follow-up. Methods We performed a secondary analysis of a cross-sectional multicentre study of Fontan patients with intra-atrial lateral tunnel (ILT) or extracardiac conduit (ECC) modification. Subjects underwent cardiac MRI during rest and low-dose dobutamine stress, and cardiopulmonary exercise testing. Atrial and diastolic ventricular function parameters were derived from volume-time curves. Medical records were abstracted for a composite end-point of death, listing for transplant, arrhythmia and reintervention. Spearman’s r correlation tests and Cox proportional hazards models were used to assess the relation between the dobutamine response for atrial and diastolic ventricular function and outcomes, including exercise capacity. Results We included 57 patients (26 ECC; 31 ILT) aged 12.8 (IQR (10.3–15.5)) years. During dobutamine stress atrial cyclic volume change increased (3.0 (0.4–5.9) mL/m2, p<0.001), as did early (1.9 (−1.6 to 3.6) mL/m2, p=0.001) and late emptying volume (2.2 (0.2–4.4) mL/m2, p<0.001). Ventricular early filling decreased (−1.6 (−5.7 to 0.7) mL/m2, p=0.046) and ventricular late filling increased (1.0 (−0.4 to 3.4) mL/m2, p<0.001) while stroke volume remained similar. Only for patients with the ECC modification, atrial early emptying volume increase correlated with peak oxygen uptake (ρ=0.66, p=0.002). No other parameter related to exercise capacity. During a median 7.1-year follow-up, 22 patients reached the composite endpoint. No parameter predicted events during the follow-up. Conclusions Dobutamine stress augmented atrial reservoir and pump function for Fontan patients. Atrial early emptying reserve related to exercise capacity in ECC patients. No other atrial or diastolic ventricular function parameter related to outcomes.
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Affiliation(s)
- Jelle P G van der Ven
- Pediatric Cardiology, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands.,Netherlands Heart Institute, Utrecht, Utrecht, The Netherlands
| | - Sjoerd S M Bossers
- Pediatric Cardiology, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Eva van den Bosch
- Pediatric Cardiology, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands.,Netherlands Heart Institute, Utrecht, Utrecht, The Netherlands
| | - Niels Dam
- Pediatric Cardiology, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Irene M Kuipers
- Department of Pediatrics, Division of Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Gabrielle G van Iperen
- Department of Pediatrics, Division of Cardiology, UMC Utrecht, Utrecht, Utrecht, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Livia Kapusta
- Department of Pediatrics, Division of Cardiology, Radboudumc, Nijmegen, Gelderland, The Netherlands.,Pediatric Cardiology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Arend D J Ten Harkel
- Department of Paediatric Cardiology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Willem A Helbing
- Paediatric Cardiology and Radiology, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
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20
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Kaptein FHJ, Stals MAM, Grootenboers M, Braken SJE, Burggraaf JLI, van Bussel BCT, Cannegieter SC, Ten Cate H, Endeman H, Gommers DAMPJ, van Guldener C, de Jonge E, Juffermans NP, Kant KM, Kevenaar ME, Koster S, Kroft LJM, Kruip MJHA, Leentjens J, Marechal C, Soei YL, Tjepkema L, Visser C, Klok FA, Huisman MV. Incidence of thrombotic complications and overall survival in hospitalized patients with COVID-19 in the second and first wave. Thromb Res 2021; 199:143-148. [PMID: 33535120 PMCID: PMC7832218 DOI: 10.1016/j.thromres.2020.12.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In the first wave, thrombotic complications were common in COVID-19 patients. It is unknown whether state-of-the-art treatment has resulted in less thrombotic complications in the second wave. METHODS We assessed the incidence of thrombotic complications and overall mortality in COVID-19 patients admitted to eight Dutch hospitals between September 1st and November 30th 2020. Follow-up ended at discharge, transfer to another hospital, when they died, or on November 30th 2020, whichever came first. Cumulative incidences were estimated, adjusted for competing risk of death. These were compared to those observed in 579 patients admitted in the first wave, between February 24th and April 26th 2020, by means of Cox regression techniques adjusted for age, sex and weight. RESULTS In total 947 patients with COVID-19 were included in this analysis, of whom 358 patients were admitted to the ICU; 144 patients died (15%). The adjusted cumulative incidence of all thrombotic complications after 10, 20 and 30 days was 12% (95% confidence interval (CI) 9.8-15%), 16% (13-19%) and 21% (17-25%), respectively. Patient characteristics between the first and second wave were comparable. The adjusted hazard ratio (HR) for overall mortality in the second wave versus the first wave was 0.53 (95%CI 0.41-0.70). The adjusted HR for any thrombotic complication in the second versus the first wave was 0.89 (95%CI 0.65-1.2). CONCLUSIONS Mortality was reduced by 47% in the second wave, but the thrombotic complication rate remained high, and comparable to the first wave. Careful attention to provision of adequate thromboprophylaxis is invariably warranted.
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Affiliation(s)
- F H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M Grootenboers
- Department of Pulmonology, Amphia Hospital Breda, the Netherlands
| | - S J E Braken
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L I Burggraaf
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - B C T van Bussel
- Department of Intensive Care Medicine, Maastricht, UMC+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - H Endeman
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - D A M P J Gommers
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - C van Guldener
- Department of Internal Medicine, Amphia Hospital Breda, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - K M Kant
- Department of Intensive Care Medicine, Amphia Hospital Breda, the Netherlands
| | - M E Kevenaar
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - S Koster
- Department of Intensive Care Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Leentjens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Marechal
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Y L Soei
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - L Tjepkema
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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21
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Kamphuis VP, Roest AAW, van den Boogaard PJ, Kroft LJM, Lamb HJ, Helbing WA, Blom NA, Westenberg JJM, Elbaz MSM. Hemodynamic interplay of vorticity, viscous energy loss, and kinetic energy from 4D Flow MRI and link to cardiac function in healthy subjects and Fontan patients. Am J Physiol Heart Circ Physiol 2021; 320:H1687-H1698. [PMID: 33635164 DOI: 10.1152/ajpheart.00806.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The purpose of this study was to directly assess (patho)physiology of intraventricular hemodynamic interplay between four-dimensional flow cardiovascular magnetic resonance imaging (4D Flow MRI)-derived vorticity with kinetic energy (KE) and viscous energy loss (EL) over the cardiac cycle and their association to ejection fraction (EF) and stroke volume (SV). Fifteen healthy subjects and thirty Fontan patients underwent whole heart 4D Flow MRI. Ventricular vorticity, KE, and EL were computed over systole (vorticity_volavg systole, KEavg systole, and ELavg systole) and diastole (vorticity_volavg diastole, KEavg diastole, and ELavg diastole). The association between vorticity_vol and KE and EL was tested by Spearman correlation. Fontan patients were grouped to normal and impaired EF groups. A significant correlation was found between SV and vorticity in healthy subjects (systolic: ρ = 0.84, P < 0.001; diastolic: ρ = 0.81, P < 0.001) and in Fontan patients (systolic: ρ = 0.61, P < 0.001; diastolic: ρ = 0.54, P = 0.002). Healthy subjects showed positive correlation between vorticity_vol versus KE (systole: ρ = 0.96, P < 0.001; diastole: ρ = 0.90, P < 0.001) and EL (systole: ρ = 0.85, P < 0.001; diastole: ρ = 0.84, P < 0.001). Fontan patients showed significantly elevated vorticity_vol compared with healthy subjects (vorticity_volavg systole: 3.1 [2.3-3.9] vs. 1.7 [1.3-2.4] L/s, P < 0.001; vorticity_volavg diastole: 3.1 [2.0-3.7] vs. 2.1 [1.6-2.8] L/s, P = 0.002). This elevated vorticity in Fontan patients showed strong association with KE (systole: ρ = 0.91, P < 0.001; diastole: ρ = 0.85, P < 0.001) and EL (systole: ρ = 0.82, P < 0.001; diastole: ρ = 0.89, P < 0.001). Fontan patients with normal EF showed significantly higher vorticity_volavg systole and ELavg systole, but significantly decreased KE avg diastole, in the presence of normal SV, compared with healthy subjects. Healthy subjects show strong physiological hemodynamic interplay between vorticity with KE and EL. Fontan patients demonstrate a pathophysiological hemodynamic interplay characterized by correlation of elevated vorticity with KE and EL in the presence of maintained normal stroke volume. Altered vorticity and energetic hemodynamics are found in the presence of normal EF in Fontan patients.NEW & NOTEWORTHY Physiologic intraventricular hemodynamic interplay/coupling is present in the healthy left ventricle between vorticity versus viscous energy loss and kinetic energy from four-dimensional flow cardiovascular magnetic resonance imaging (4D Flow MRI). Conversely, Fontan patients present compensatory pathophysiologic hemodynamic coupling by an increase in intraventricular vorticity that positively correlates to viscous energy loss and kinetic energy levels in the presence of maintained normal stroke volume. Altered vorticity and energetics are found in the presence of normal ejection fraction in Fontan patients.
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Affiliation(s)
- Vivian P Kamphuis
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Academic Medical Center, Amsterdam, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammed S M Elbaz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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22
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van Dam LF, Kroft LJM, Huisman MV, Ninaber MK, Klok FA. Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism. TH Open 2021; 5:e66-e72. [PMID: 33585787 PMCID: PMC7875679 DOI: 10.1055/s-0041-1723782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background
Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE.
Patients and Methods
This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death.
Results
We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (
n
= 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (
n
= 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19,
p
= 0.02).
Conclusion
CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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van Dam LF, Kroft LJM, Boon GJAM, Huisman MV, Ninaber MK, Klok FA. Computed tomography pulmonary perfusion imaging and 3-months clinical outcomes after acute pulmonary embolism. Thromb Res 2020; 199:32-34. [PMID: 33387875 DOI: 10.1016/j.thromres.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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24
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den Exter PL, Kroft LJM, Gonsalves C, Le Gal G, Schaefer-Prokop CM, Carrier M, Huisman MV, Klok FA. Establishing diagnostic criteria and treatment of subsegmental pulmonary embolism: A Delphi analysis of experts. Res Pract Thromb Haemost 2020; 4:1251-1261. [PMID: 33313465 PMCID: PMC7695556 DOI: 10.1002/rth2.12422] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/25/2020] [Accepted: 07/04/2020] [Indexed: 12/27/2022] Open
Abstract
Background Improved imaging techniques have increased the incidence of subsegmental pulmonary embolism (ssPE). Indirect evidence is suggesting that ssPE may represent a more benign presentation of venous thromboembolism not necessarily requiring anticoagulant treatment. However, correctly diagnosing ssPE is challenging with reported low interobserver agreement, partly due to the lack of widely accepted diagnostic criteria. Objectives We sought to derive uniform diagnostic criteria for ssPE, guided by expert consensus. Methods Based on an extensive literature review and expert opinion of a Delphi steering committee, two surveys including statements regarding diagnostic criteria and management options for ssPE were established. These surveys were conducted electronically among two panels, respectively: expert thoracic radiologists and clinical venous thromboembolism specialists. The Delphi method was used to achieve consensus after multiple survey rounds. Consensus was defined as a level of agreement >70%. Results Twenty‐nine of 40 invited radiologists (73%) and 40 of 51 clinicians (78%) participated. Following two survey rounds by the expert radiologists, consensus was achieved on 15 of 16 statements, including on the established diagnostic criteria for ssPE (96% agreement): a contrast defect in a subsegmental artery, that is, the first arterial branch division of any segmental artery independent of artery diameter, visible in at least two subsequent axial slices, using a computed tomography scanner with a desired maximum collimator width of ≤1 mm. These criteria were approved by 83% of the clinical venous thromboembolism (VTE) specialists. The clinical expert panel favored anticoagulant treatment in case of prior VTE, antiphospholipid syndrome, pregnancy, cancer, and proximal deep vein thrombosis. Conclusion The results of this analysis provide standard radiological criteria for ssPE that may be applicable in both clinical trials and practice.
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Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Lucia J M Kroft
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
| | - Carol Gonsalves
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Gregoire Le Gal
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Cornelia M Schaefer-Prokop
- Diagnostic Image Analysis Group Department of Radiology and Nuclear Medicine Radboud University Medical Center Nijmegen The Netherlands.,Department of Radiology Meander Medisch Centrum Amersfoort The Netherlands
| | - Marc Carrier
- Department of Medicine Ottawa Hospital Research Institute at the University of Ottawa Ontario Canada
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
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25
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Hendriks SV, Klok FA, den Exter PL, Eijsvogel M, Faber LM, Hofstee HMA, Iglesias Del Sol A, Kroft LJM, Mairuhu ATA, Huisman MV. Right Ventricle-to-Left Ventricle Diameter Ratio Measurement Seems to Have No Role in Low-Risk Patients with Pulmonary Embolism Treated at Home Triaged by Hestia Criteria. Am J Respir Crit Care Med 2020; 202:138-141. [PMID: 32203673 DOI: 10.1164/rccm.202002-0267le] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephan V Hendriks
- Leiden University Medical CenterLeiden, the Netherlands.,Haga Teaching HospitalThe Hague, the Netherlands
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26
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van Dam LF, Klok FA, Tushuizen ME, Ageno W, Darwish Murad S, van Haren GR, Huisman MV, Lauw MN, Iglesias Del Sol A, Wasser MNJM, Willink Y, Kroft LJM. Magnetic Resonance Thrombus Imaging to Differentiate Acute from Chronic Portal Vein Thrombosis. TH Open 2020; 4:e224-e230. [PMID: 32984756 PMCID: PMC7511264 DOI: 10.1055/s-0040-1716716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction
Timely diagnosis and treatment of portal vein thrombosis (PVT) is crucial to prevent morbidity and mortality. However, current imaging tests cannot always accurately differentiate acute from chronic (nonocclusive) PVT. Magnetic resonance noncontrast thrombus imaging (MR-NCTI) has been shown to accurately differentiate acute from chronic venous thrombosis at other locations and may also be of value in the diagnostic management of PVT. This study describes the first phase of the Rhea study (NTR 7061). Our aim was to select and optimize MR-NCTI sequences that would be accurate for differentiation of acute from chronic PVT.
Study Design
The literature was searched for different MRI sequences for portal vein and acute thrombosis imaging. The most promising sequences were tested in a healthy volunteer followed by one patient with acute PVT and two patients with chronic PVT, all diagnosed on (repetitive) contrast-enhanced computed tomography (CT) venography to optimize the MR-NCTI sequences. All images were evaluated by an expert panel.
Results
Several MR-NCTI sequences were identified and tested. Differentiation of acute from chronic PVT was achieved with 3D T1 TFE (three-dimensional T1 turbo field echo) and 3D T1 Dixon FFE (three-dimensional T1 fast field echo) sequences with best image quality. The expert panel was able to confirm the diagnosis of acute PVT on the combined two MR-NCTI sequences and to exclude acute PVT in the two patients with chronic PVT.
Conclusion
Using 3D T1 TFE and 3D T1 Dixon FFE sequences, we were able to distinguish acute from chronic PVT. This clinical relevant finding will be elucidated in clinical studies to establish their test performance.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Guido R van Haren
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mandy N Lauw
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Martin N J M Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ysbrand Willink
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Ciaffi J, van Leeuwen NM, Boonstra M, Kroft LJM, Schouffoer AA, Ninaber MK, Huizinga TWJ, de Vries-Bouwstra JK. Evolution of interstitial lung disease one year after hematopoietic stem cell transplantation or cyclophosphamide for systemic sclerosis. Arthritis Care Res (Hoboken) 2020; 74:433-441. [PMID: 32961038 PMCID: PMC9303567 DOI: 10.1002/acr.24451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/13/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
Objective Hematopoietic stem cell transplantation (HSCT) and cyclophosphamide (CYC) are treatment options for progressive systemic sclerosis associated with interstitial lung disease (SSc‐ILD). The aims of our retrospective observational study were to evaluate: 1) the evolution of SSc‐ILD in SSc patients treated with HSCT (assessed by high‐resolution computed tomography [HRCT]; a group of patients treated with CYC was included as frame of reference); 2) how results of pulmonary function tests (PFTs) are associated with HRCT findings; and 3) which factors predict ILD reduction. Methods We semiquantitatively scored total ILD extent, reticulations, and ground‐glass opacities (GGO) scores at baseline and at the 1‐year HRCTs of SSc patients treated with HSCT or CYC. Linear association between changes in HRCT scores and PFT results and predictors of ILD improvement were studied. Results We included 51 patients (those treated with HSCT [n = 20] and those treated with CYC [n = 31]). The mean change in total ILD score was –5.1% (95% confidence interval [95% CI] –10.2, 0.0) in the HSCT treatment group (P = 0.050), and –1.0% (95% CI –4.3, 2.3) in the CYC treatment group (P = 0.535). For all patients, the evolution of HRCT scores was weakly associated with relative changes in PFT results. In univariate logistic regression, higher ground‐glass opacities, higher total ILD, and lower single‐breath diffusing capacity for carbon monoxide scores at baseline predicted improvement of ILD extent after treatment, but a multivariable model could not be built to assess independency of predictors. Conclusion One year after treatment with HSCT, a nonsignificant but clear reduction of SSc‐ILD extent was observed. Changes in PFT results were associated with changes in HRCT scores but the correlation was weak and cannot be considered conclusive.
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Affiliation(s)
- Jacopo Ciaffi
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Rheumatology Unit, Azienda Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy.,Medicine and Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Nina M van Leeuwen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maaike Boonstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anne A Schouffoer
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Haga Teaching Hospital, the Hague, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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28
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Klok FA, Kroft LJM, Huisman MV. [Acute subsegmental pulmonary embolism: could it sometimes be better not to treat?]. Ned Tijdschr Geneeskd 2020; 164:D4717. [PMID: 32940974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Diagnosis of 'subsegmental pulmonary embolism' has been on the rise since the introduction of modern CT scanners. The need to treat patients with these relatively small thrombi is under discussion. On the one hand, there is clear evidence of overdiagnosis. On the other hand, studies show that patients with subsegmental pulmonary embolisms have the same prognosis as patients with more proximal pulmonary embolisms. Based on currently available evidence, most patients with subsegmental pulmonary embolism should be treated with anticoagulation. A wait-and-see approach should only be considered in patients who are not at risk for new venous thromboembolism and in whom deep venous thrombosis has been ruled out. A European randomised study that starts in 2020 should determine whether it is indeed better not to treat this last group of patients.
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Affiliation(s)
- Frederikus A Klok
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase,Leiden
- Contact: Frederikus A. Klok
| | | | - Menno V Huisman
- Leids Universitair Medisch Centrum, afd. Trombose en Hemostase,Leiden
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29
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van Dam LF, Gautam G, Dronkers CEA, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Safety of using the combination of the Wells rule and D-dimer test for excluding acute recurrent ipsilateral deep vein thrombosis. J Thromb Haemost 2020; 18:2341-2348. [PMID: 32613731 PMCID: PMC7497055 DOI: 10.1111/jth.14986] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnostic accuracy of clinical probability assessment and D-dimer testing for clinically suspected recurrent deep vein thrombosis (DVT) is largely unknown. AIM To evaluate the safety of ruling out acute recurrent DVT based on an unlikely Wells score for DVT and a normal D-dimer test. METHODS This was a predefined endpoint of the Theia study in which the diagnostic accuracy of magnetic resonance direct thrombus imaging in acute recurrent ipsilateral DVT was validated. The Wells rule and D-dimer test, performed as part of the study protocol, were not used for management decisions. The primary outcome of this analysis was the incidence of recurrent DVT at baseline or during 3-month follow-up for patients with an unlikely Wells score and a normal D-dimer test. RESULTS Results of both Wells score and D-dimer tests were available in 231 patients without anticoagulant treatment. The recurrent DVT prevalence was 45% (103/231). Forty-nine patients had an unlikely Wells score and normal D-dimer test, of whom 3 (6.1%, 95% confidence interval [CI] 1.3%-18%) had recurrent DVT at baseline/follow-up, yielding a sensitivity of 97% (95% CI 92%-99%) and specificity of 36% (95% CI 28%-45%). Thus, if clinical probability scoring and D-dimer testing would have been applied, radiological imaging could have been omitted in 21% of patients with a diagnostic failure rate of 6.1%. CONCLUSION By applying clinical probability scoring and D-dimer testing, radiological imaging could be spared in one fifth of patients with suspected recurrent ipsilateral DVT. However, the high failure rate does not support implementation of this strategy in daily practice.
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Affiliation(s)
- Lisette F. van Dam
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gargi Gautam
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Charlotte E. A. Dronkers
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | - Waleed Ghanima
- Department of Internal MedicineØstfold Hospital TrustØstfoldNorway
- Department of HaematologyInstitute of Clinical MedicineUniversity of OsloOsloNorway
| | | | - Anders von Heijne
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Herman M. A. Hofstee
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | | | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Stan Kolman
- Department of Vascular MedicineDiakonessenhuisUtrechtthe Netherlands
| | | | - Mathilde Nijkeuter
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | | | | | | | - Jan Westerink
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Eli Westerlund
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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30
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van Dam LF, Kroft LJM, van der Wal LI, Cannegieter SC, Eikenboom J, de Jonge E, Huisman MV, Klok FA. Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease? Thromb Res 2020; 193:86-89. [PMID: 32531548 PMCID: PMC7274953 DOI: 10.1016/j.thromres.2020.06.010] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 infections are associated with a high prevalence of venous thromboembolism, particularly pulmonary embolism (PE). It is suggested that COVID-19 associated PE represents in situ immunothrombosis rather than venous thromboembolism, although the origin of thrombotic lesions in COVID-19 patients remains largely unknown. METHODS In this study, we assessed the clinical and computed tomography (CT) characteristics of PE in 23 consecutive patients with COVID-19 pneumonia and compared these to those of 100 consecutive control patients diagnosed with acute PE before the COVID-19 outbreak. Specifically, RV/LV diameter ratio, pulmonary artery trunk diameter and total thrombus load (according to Qanadli score) were measured and compared. RESULTS We observed that all thrombotic lesions in COVID-19 patients were found to be in lung parenchyma affected by COVID-19. Also, the thrombus load was lower in COVID-19 patients (Qanadli score -8%, 95% confidence interval [95%CI] -16 to -0.36%) as was the prevalence of the most proximal PE in the main/lobar pulmonary artery (17% versus 47%; -30%, 95%CI -44% to -8.2). Moreover, the mean RV/LV ratio (mean difference -0.23, 95%CI -0.39 to -0.07) and the prevalence of RV/LV ratio >1.0 (prevalence difference -23%, 95%CI -41 to -0.86%) were lower in the COVID-19 patients. CONCLUSION Our findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19, fuelling the discussion on its pathophysiology.
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Affiliation(s)
- L F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L I van der Wal
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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31
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Noordegraaf AV, Klok FA. Correction: Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0234298. [PMID: 32484829 PMCID: PMC7266560 DOI: 10.1371/journal.pone.0234298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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32
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van Broekhoven I, Kroft LJM, van der Palen RLF. Imaging large arteries after arterial switch operation. Heart 2020; 106:891-950. [PMID: 32461258 DOI: 10.1136/heartjnl-2019-316504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Iris van Broekhoven
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Vonk Noordegraaf A, Klok FA. Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0232354. [PMID: 32343741 PMCID: PMC7188241 DOI: 10.1371/journal.pone.0232354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood. Poor-quality anticoagulation may contribute to a higher risk of CTEPH after acute pulmonary embolism (PE), partly explaining the transition from acute PE to CTEPH. We assessed the association between the time in therapeutic range (TTR) of vitamin-K antagonist (VKA) treatment and incidence of CTEPH after a PE diagnosis. METHODS Case-control study in which the time spent in, under and above therapeutic range was calculated in 44 PE patients who were subsequently diagnosed with CTEPH (cases). Controls comprised 150 consecutive PE patients in whom echocardiograms two years later did not show pulmonary hypertension. All patients were treated with VKA for at least 6 months after the PE diagnosis. Time in (TTR), under and above range were calculated. Mean differences between cases and controls were estimated by linear regression. RESULTS Mean TTR during the initial 6-month treatment period was 72% in cases versus 78% in controls (mean difference -6%, 95%CI -12 to -0.1), mainly explained by more time above the therapeutic range in the cases. Mean difference of time under range was 0% (95%CI -6 to 7) and 2% (95CI% -3 to 7) during the first 3 and 6 months, respectively. In a multivariable model, adjusted odds ratios (ORs) for CTEPH were around unity considering different thresholds for 'poor anticoagulation', i.e. TTR <50%, <60% and <70%. CONCLUSION Subtherapeutic initial anticoagulation was not more prevalent among PE patients diagnosed with CTEPH than in those who did not develop CTEPH.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J. M. van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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34
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van Dam LF, van Walderveen MAA, Kroft LJM, Kruyt ND, Wermer MJH, van Osch MJP, Huisman MV, Klok FA. Current imaging modalities for diagnosing cerebral vein thrombosis - A critical review. Thromb Res 2020; 189:132-139. [PMID: 32220779 DOI: 10.1016/j.thromres.2020.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/17/2020] [Accepted: 03/17/2020] [Indexed: 12/19/2022]
Abstract
Cerebral vein thrombosis (CVT) is a rare presentation of venous thromboembolism. Prompt and accurate diagnosis is essential as delayed recognition and treatment may lead to permanent disability or even death. Since no validated diagnostic algorithms exist, the diagnosis of CVT mainly relies on neuroimaging. Digital subtraction angiography (DSA) is the historical diagnostic standard for CVT, but is rarely used nowadays and replaced by computed tomography (CT) and magnetic resonance imaging (MRI). High quality studies to evaluate the diagnostic test characteristics of state of the art imaging modalities are however unavailable to date. This review provides an overview of the best available evidence regarding the diagnostic performance of CT and MRI for the diagnosis of CVT. Notably, available studies are observational, mostly small, outdated, and with a high risk of bias. Therefore, direct comparison between studies is difficult due to large diversity in study design, imaging method, reference standard, patient selection and sample size. In general, contrast-enhanced techniques are more accurate for the diagnosis of CVT then non-contrast-enhanced techniques. CT venography and MRI have been both reported to be adequate for establishing a final diagnosis of CVT, but choice of modality as used in clinical practice depends on availability, local preference and experience, as well as patient characteristics. Our review underlines the need for high-quality diagnostic studies comparing CT venography and MRI in specific settings, to improve clinical care and standardize clinical trials.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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van der Ven JPG, Alsaied T, Juggan S, Bossers SSM, van den Bosch E, Kapusta L, Kuipers IM, Kroft LJM, Ten Harkel ADJ, van Iperen GG, Rathod RH, Helbing WA. Atrial function in Fontan patients assessed by CMR: Relation with exercise capacity and long-term outcomes. Int J Cardiol 2020; 312:56-61. [PMID: 32139238 DOI: 10.1016/j.ijcard.2020.02.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/21/2020] [Accepted: 02/23/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the role of atrial function on exercise capacity and clinical events in Fontan patients. DESIGN We included 96 Fontan patients from 6 tertiary centers, aged 12.8 (IQR 10.1-15.6) years, who underwent cardiac magnetic resonance imaging and cardiopulmonary exercise testing within 12 months of each other from 2004 to 2017. Intra-atrial lateral tunnel (ILT) and extracardiac conduit (ECC) patients were matched 1:1 with regard to age, gender and dominant ventricle. The pulmonary venous atrium was manually segmented in all phases and slices. Atrial function was assessed by volume-time curves. Furthermore, atrial longitudinal and circumferential feature tracking strain was assessed. We determined the relation between atrial function and exercise capacity, assessed by peak oxygen uptake and VE/VCO2 slope, and events (mortality, listing for transplant, re-intervention, arrhythmia) during follow-up. RESULTS Atrial maximal and minimal volumes did not differ between ILT and ECC patients. ECC patients had higher reservoir function (21.1 [16.4-28.0]% vs 18.2 [10.9-22.2]%, p = .03), lower conduit function and lower total circumferential strain (13.8 ± 5.1% vs 18.0 ± 8.7%, p = .01), compared to ILT patients. Only for ECC patients, a better late peak circumferential strain rate predicted better VE/VCO2 slope. No other parameter of atrial function predicted peak oxygen uptake or VE/VCO2 slope. During a median follow-up of 6.2 years, 42 patients reached the composite end-point. No atrial function parameters predicted events during follow-up. CONCLUSIONS ECC patients have higher atrial reservoir function and lower conduit function. Atrial function did not predict exercise capacity or events during follow-up.
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Affiliation(s)
- Jelle P G van der Ven
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Tarek Alsaied
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Cardiology, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Saeed Juggan
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sjoerd S M Bossers
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Eva van den Bosch
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Livia Kapusta
- Department of Pediatrics, Division of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; Pediatric Cardiology Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Irene M Kuipers
- Department of Pediatrics, Division of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatrics, Division of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Gabrielle G van Iperen
- Department of Pediatrics, Division of Cardiology, University Medical Centre Utrecht - Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Willem A Helbing
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Radiology, Erasmus Medical Centre, Rotterdam, the Netherlands; Department of Pediatrics, Division of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Uzorka JW, Wallinga J, Kroft LJM, Ottenhoff THM, Arend SM. Radiological Signs of Latent Tuberculosis on Chest Radiography: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2019; 6:5541696. [PMID: 31363778 PMCID: PMC6667719 DOI: 10.1093/ofid/ofz313] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/08/2019] [Indexed: 01/15/2023] Open
Abstract
Objective Current guidelines recommend screening for latent tuberculosis infection (LTBI) with a tuberculin skin test (TST) or interferon gamma release assay (IGRA), or both. Many also recommend chest radiography (CXR), although its added value is uncertain. This systematic review assessed the prevalence of abnormalities suggestive of LTBI on CXR (LTBI-CXR lesions) and evaluated the strength of the association. Method We searched 4 databases up to September 2017 and systematically reviewed cross-sectional and cohort studies reporting LTBI-CXR lesions in individuals with a positive TST or IGRA, or both, result. Prevalence estimates were pooled using random effects models and odds ratios (ORs) were used to calculate risk estimates. Results In the 26 included studies, the pooled proportion of individuals with LTBI having LTBI-CXR lesions was 0.15 (95% confidence interval [CI], 0.12–0.18]. In 16 studies that reported on individuals with LTBI and uninfected controls, LTBI-CXR lesions were associated with a positive TST result ≥ 5 mm or ≥ 10 mm (OR, 2.45; 95% CI, 1.00–5.99; and OR, 2.06; 95% CI, 1.38–3.09, respectively) and with a positive QuantiFERON result (OR, 1.99; 95% CI, 1.17–3.39) compared to CXR in uninfected controls. Although few studies reported specified lesions, calcified nodules were most frequently reported in individuals with LTBI (proportion, 0.07; 95% CI, 0.02–0.11). Conclusions Lesions on CXR suggestive of previous infection with Mycobacterium tuberculosis were significantly associated with positive tests for LTBI, although the sensitivity was only 15%. This finding may have added value when detection of past LTBI is important but immunodiagnostic tests may be unreliable.
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Affiliation(s)
- Jonathan W Uzorka
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
| | - Jacco Wallinga
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
| | - Sandra M Arend
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
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Kamphuis VP, Elbaz MSM, van den Boogaard PJ, Kroft LJM, Lamb HJ, Hazekamp MG, Jongbloed MRM, Blom NA, Helbing WA, Roest AAW, Westenberg JJM. Stress increases intracardiac 4D flow cardiovascular magnetic resonance -derived energetics and vorticity and relates to VO 2max in Fontan patients. J Cardiovasc Magn Reson 2019; 21:43. [PMID: 31340834 PMCID: PMC6657113 DOI: 10.1186/s12968-019-0553-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/14/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We hypothesize that dobutamine-induced stress impacts intracardiac hemodynamic parameters and that this may be linked to decreased exercise capacity in Fontan patients. Therefore, the purpose of this study was to assess the effect of pharmacologic stress on intraventricular kinetic energy (KE), viscous energy loss (EL) and vorticity from four-dimensional (4D) Flow cardiovascular magnetic resonance (CMR) imaging in Fontan patients and to study the association between stress response and exercise capacity. METHODS Ten Fontan patients underwent whole-heart 4D flow CMR before and during 7.5 μg/kg/min dobutamine infusion and cardiopulmonary exercise testing (CPET) on the same day. Average ventricular KE, EL and vorticity were computed over systole, diastole and the total cardiac cycle (vorticity_volavg cycle, KEavg cycle, ELavg cycle). The relation to maximum oxygen uptake (VO2 max) from CPET was tested by Pearson's correlation or Spearman's rank correlation in case of non-normality of the data. RESULTS Dobutamine stress caused a significant 88 ± 52% increase in KE (KEavg cycle: 1.8 ± 0.5 vs 3.3 ± 0.9 mJ, P < 0.001), a significant 108 ± 49% increase in EL (ELavg cycle: 0.9 ± 0.4 vs 1.9 ± 0.9 mW, P < 0.001) and a significant 27 ± 19% increase in vorticity (vorticity_volavg cycle: 3441 ± 899 vs 4394 ± 1322 mL/s, P = 0.002). All rest-stress differences (%) were negatively correlated to VO2 max (KEavg cycle: r = - 0.83, P = 0.003; ELavg cycle: r = - 0.80, P = 0.006; vorticity_volavg cycle: r = - 0.64, P = 0.047). CONCLUSIONS 4D flow CMR-derived intraventricular kinetic energy, viscous energy loss and vorticity in Fontan patients increase during pharmacologic stress and show a negative correlation with exercise capacity measured by VO2 max.
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Affiliation(s)
- Vivian P. Kamphuis
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mohammed S. M. Elbaz
- Department of Radiology Feinberg School of Medicine, Northwestern University, Chicago, USA
| | | | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J. Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nico A. Blom
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Pediatrics division of Pediatric Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics division of Pediatric Cardiology, Radboud university Medical Center, Nijmegen, the Netherlands
| | - Arno A. W. Roest
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jos J. M. Westenberg
- Department of Radiology Feinberg School of Medicine, Northwestern University, Chicago, USA
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van der Pol LM, Tromeur C, Faber LM, van der Hulle T, Kroft LJM, Mairuhu ATA, de Roos A, Huisman MV, Klok FA. Chest X-Ray Not Routinely Indicated Prior to the YEARS Algorithm in the Diagnostic Management of Suspected Pulmonary Embolism. TH Open 2019; 3:e22-e27. [PMID: 31249978 PMCID: PMC6524889 DOI: 10.1055/s-0038-1676812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022] Open
Abstract
Background The YEARS algorithm was designed to simplify the diagnostic process of suspected pulmonary embolism (PE) and to reduce the number of required computed tomography pulmonary angiography (CTPA) scans. Chest X-ray (CXR) is often used as initial imaging test in patients suspected for PE. Aim To determine if CXR results differ between patients with confirmed PE and with PE ruled out, and to investigate whether CXR provides incremental diagnostic value to the YEARS criteria that is used for selecting patients with CTPA indication. Methods This post-hoc analysis concerned 1,473 consecutive patients with suspected PE who were managed according to YEARS and were subjected to CXR as part of routine care. The prevalence and likelihood ratios of seven main CXR findings for a final diagnosis of PE were calculated. Results A total of 214 patients were diagnosed with PE at baseline (15%). Abnormal CXR occurred more often in patients with confirmed PE (36%, 77/214) than in patients without PE (26%; 327/1,259), for an odds ratio of 1.60 (95% confidence interval: 1.18-2.18). Only the unexpected finding of a (rib)fracture or pneumothorax, present in as few as six patients (0.4%), significantly lowered the post-test probability of PE to an extent that CTPA could have been avoided. Conclusion The incremental diagnostic value of CXR to the YEARS algorithm to rule out PE was limited. CXR was more frequently abnormal in patients with PE than in those in whom PE was ruled out. These data do not support to perform CXR routinely in all patients with suspected PE, prior to CTPA imaging.
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Affiliation(s)
- Liselotte M van der Pol
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Cecile Tromeur
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Groupe d'Etude de la Thrombose de Bretagne Occidentale, Department of Internal Medicine and Chest Diseases, University of Brest, CHRU Brest, Brest, France
| | - Laura M Faber
- Department of Internal Medicine, Red Cross Hospital, Beverwijk, The Netherlands
| | - Tom van der Hulle
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Albert de Roos
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Dronkers CEA, Klok FA, van Langevelde K, Šrámek A, van Haren GR, Huisman MV, de Roos A, Kroft LJM. Diagnosing Recurrent DVT of the Leg by Two Different Non-Contrast-Enhanced Magnetic Resonance Direct Thrombus Imaging Techniques: A Pilot Study. TH Open 2019; 3:e37-e44. [PMID: 31249980 PMCID: PMC6524903 DOI: 10.1055/s-0039-1678683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/02/2019] [Indexed: 11/12/2022] Open
Abstract
Introduction
Magnetic resonance direct thrombus imaging (MRDTI) is a promising technique to improve the diagnostic management of patients with a suspected ipsilateral recurrent deep vein thrombosis (DVT) by direct visualization of a thrombus. Another magnetic resonance imaging (MRI) technique, T1-weighted turbo spin-echo spectral attenuated inversion recovery (TSE-SPAIR), has the potential to image a thrombus directly with a high spatial resolution as well. The main aim of this pilot study was to investigate if adding the TSE-SPAIR sequence to an MRDTI sequence performed in patients with suspected recurrent DVT may increase the diagnostic confidence of expert MRDTI readers.
Methods
Fifteen patients with suspected acute recurrent DVT were included in this study. The TSE-SPAIR sequence was scanned directly after the MRDTI scan but not used to guide clinical decision making, and both scans were adjudicated post hoc two times separately by three independent expert MRDTI readers. Diagnostic confidence was scored on a 4-point Likert scale: (1) poor (definite diagnosis impossible), (2) fair (evaluation of major findings possible), (3) good (definite diagnosis possible), and (4) excellent (exact diagnosis possible).
Results
The diagnostic confidence of expert readers increased when adding the TSE-SPAIR sequence on top of the MRDTI sequence from “good” (median, 3.0; interquartile range [IQR], 2.66–3.0) to “excellent” (median, 3.67; IQR 3.33–3.67;
p
= 0.001). Evaluation of the scans in the reversed order 5 months after initial reading showed similar results. Diagnostic accuracy for proximal DVT of both scan techniques was good.
Conclusion
The extra TSE-SPAIR sequence may help increase diagnostic confidence of radiologists in cases of uncertain diagnosis in patients with suspected ipsilateral recurrent DVT.
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Affiliation(s)
- Charlotte E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kirsten van Langevelde
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Radiology, HAGA Teaching Hospital, The Hague, The Netherlands
| | - Alexandr Šrámek
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Guido R van Haren
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert de Roos
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Bruyndonckx L, Kroft LJM, Bekker V, Roest AAW, van der Palen RLF. Umbilical Vein Catheter Protruding Through a Pulmonary Vein in a Patient with an Infracardiac Type Total Abnormal Pulmonary Venous Drainage. Pediatr Cardiol 2019; 40:878-879. [PMID: 30929066 PMCID: PMC6451718 DOI: 10.1007/s00246-019-02094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/13/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Luc Bruyndonckx
- Department of Paediatric Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. .,Translational Research in Immunology and Inflammation, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium.
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Vincent Bekker
- Department of Neonatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Arno A. W. Roest
- Department of Paediatric Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Roel L. F. van der Palen
- Department of Paediatric Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Kamphuis VP, Roest AAW, Ajmone Marsan N, van den Boogaard PJ, Kroft LJM, Aben JP, Bax JJ, de Roos A, Lamb HJ, Westenberg JJM. Automated Cardiac Valve Tracking for Flow Quantification with Four-dimensional Flow MRI. Radiology 2018; 290:70-78. [PMID: 30375924 DOI: 10.1148/radiol.2018180807] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare four-dimensional flow MRI with automated valve tracking to manual valve tracking in patients with acquired or congenital heart disease and healthy volunteers. Materials and Methods In this retrospective study, data were collected from 114 patients and 46 volunteers who underwent four-dimensional flow MRI at 1.5 T or 3.0 T from 2006 through 2017. Among the 114 patients, 33 had acquired and 81 had congenital heart disease (median age, 17 years; interquartile range [IQR], 13-49 years), 51 (45%) were women, and 63 (55%) were men. Among the 46 volunteers (median age, 28 years; IQR, 22-36 years), there were 19 (41%) women and 27 (59%) men. Two orthogonal cine views of each valve were used for valve tracking. Wilcoxon signed-rank test was used to compare analysis times, net forward volumes (NFVs), and regurgitant fractions. Intra- and interobserver variability was tested by using intraclass correlation coefficients (ICCs). Results Analysis time was shorter for automated versus manual tracking (all patients, 14 minutes [IQR, 12-15 minutes] vs 25 minutes [IQR, 20-25 minutes]; P < .001). Although overall differences in NFV and regurgitant fraction were comparable between both methods, NFV variation over four valves was smaller for automated versus manual tracking (all patients, 4.9% [IQR, 3.3%-6.7%] vs 9.8% [IQR, 5.1%-14.7%], respectively; P < .001). Regurgitation severity was discordant for seven pulmonary valves, 22 mitral valves, and 21 tricuspid valves. Intra- and interobserver agreement for automated tracking was excellent for NFV assessment (intra- and interobserver, ICC ≥ 0.99) and strong to excellent for regurgitant fraction assessment (intraobserver, ICC ≥ 0.94; interobserver, ICC ≥ 0.89). Conclusion Automated valve tracking reduces analysis time and improves reliability of valvular flow quantification with four-dimensional flow MRI in patients with acquired or congenital heart disease and in healthy volunteers. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by François in this issue.
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Affiliation(s)
- Vivian P Kamphuis
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Arno A W Roest
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Nina Ajmone Marsan
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Pieter J van den Boogaard
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Lucia J M Kroft
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Jean-Paul Aben
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Jeroen J Bax
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Albert de Roos
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Hildo J Lamb
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
| | - Jos J M Westenberg
- From the Department of Pediatrics, Division of Pediatric Cardiology (V.P.K., A.A.W.R.), Department of Radiology (P.J.v.d.B., L.J.M.K., A.d.R., H.J.L., J.J.M.W.), and Department of Cardiology (N.A.M., J.J.B.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands (V.P.K.); and Pie Medical Imaging BV, Maastricht, the Netherlands (J.P.A.)
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van den Bosch E, Bossers SSM, Robbers-Visser D, Boersma E, Roos-Hesselink JW, Breur HMPJ, Blom NA, Kroft LJM, Snoeren MM, Kapusta L, Helbing WA. Ventricular Response to Dobutamine Stress CMR Is a Predictor for Outcome in Fontan Patients. JACC Cardiovasc Imaging 2018; 12:368-370. [PMID: 30343077 DOI: 10.1016/j.jcmg.2018.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
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van der Pol LM, Bistervels IM, van Mens TE, van der Hulle T, Beenen LFM, den Exter PL, Kroft LJM, Mairuhu ATA, Middeldorp S, van Werkhoven JM, Ten Wolde M, Huisman MV, Klok FA. Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm. Br J Haematol 2018; 183:629-635. [PMID: 30198551 PMCID: PMC6282699 DOI: 10.1111/bjh.15556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
The rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.
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Affiliation(s)
- Liselotte M van der Pol
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Thijs E van Mens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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44
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Tromeur C, van der Pol LM, Le Roux PY, Ende-Verhaar Y, Salaun PY, Leroyer C, Couturaud F, Kroft LJM, Huisman MV, Klok FA. Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis. Haematologica 2018; 104:176-188. [PMID: 30115658 PMCID: PMC6312023 DOI: 10.3324/haematol.2018.196121] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/14/2018] [Indexed: 01/19/2023] Open
Abstract
Differences between computed tomography pulmonary angiography and ventilation-perfusion lung scanning in pregnant patients with suspected acute pulmonary embolism are not well-known, leading to ongoing debate on which test to choose. We searched in PubMed, EMBASE, Web of Science and the Cochrane Library databases and identified all relevant articles and abstracts published up to October 1, 2017. We assessed diagnostic efficiency, frequency of non-diagnostic results and maternal and fetal exposure to radiation exposure. We included 13 studies for the diagnostic efficiency analysis, 30 for the analysis of non-diagnostic results and 22 for the radiation exposure analysis. The pooled rate of false negative test results was 0% for both imaging strategies with overlapping confidence intervals. The pooled rates of non-diagnostic results with computed tomography pulmonary angiography and ventilation-perfusion lung scans were 12% (95% confidence interval: 8-17) and 14% (95% confidence interval: 10-18), respectively. Reported maternal and fetal radiation exposure doses were well below the safety threshold, but could not be compared between the two diagnostic methods given the lack of high quality data. Both imaging tests seem equally safe to rule out pulmonary embolism in pregnancy. We found no significant differences in efficiency and radiation exposures between computed tomography pulmonary angiography and ventilation-perfusion lung scanning although direct comparisons were not possible.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands .,Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, the Hague, the Netherlands
| | | | - Yvonne Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | | | - Christophe Leroyer
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Francis Couturaud
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
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45
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Klok FA, Meijboom LJ, Kroft LJM, Beenen LFM, Boon GJAM, Middeldorp S, Huisman MV, Bogaard HJ, Vonk Noordegraaf A, Ende-Verhaar YM. P1625Identification of chronic thromboembolic pulmonary hypertension on standard computed tomography pulmonary angiography for suspected acute pulmonary embolism. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- F A Klok
- Leiden University Medical Center, Leiden, Netherlands
| | - L J Meijboom
- VU University Medical Center, Amsterdam, Netherlands
| | - L J M Kroft
- Leiden University Medical Center, Leiden, Netherlands
| | - L F M Beenen
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands
| | - G J A M Boon
- Leiden University Medical Center, Leiden, Netherlands
| | - S Middeldorp
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Leiden University Medical Center, Leiden, Netherlands
| | - H J Bogaard
- VU University Medical Center, Amsterdam, Netherlands
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46
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Kamphuis VP, Elbaz MSM, van den Boogaard PJ, Kroft LJM, van der Geest RJ, de Roos A, Helbing WA, Blom NA, Westenberg JJM, Roest AAW. Disproportionate intraventricular viscous energy loss in Fontan patients: analysis by 4D flow MRI. Eur Heart J Cardiovasc Imaging 2018; 20:323-333. [DOI: 10.1093/ehjci/jey096] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/27/2018] [Accepted: 06/30/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Vivian P Kamphuis
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
- Netherlands Heart Institute, Holland Heart House, Moreelsepark 1, EP Utrecht, The Netherlands
| | - Mohammed S M Elbaz
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Ave, Suite 1600, Chicago, IL, USA
| | - Pieter J van den Boogaard
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Rob J van der Geest
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Albert de Roos
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Doctor Molewaterplein 40, GD Rotterdam, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
- Division of Pediatric Cardiology, Department of Pediatrics, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
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47
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Bilsen MP, van Meijgaarden KE, de Jong HK, Joosten SA, Prins C, Kroft LJM, Jonker JT, Crobach S, Pelger RC, Ottenhoff THM, Arend SM. A novel view on the pathogenesis of complications after intravesical BCG for bladder cancer. Int J Infect Dis 2018; 72:63-68. [PMID: 29778583 DOI: 10.1016/j.ijid.2018.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 11/17/2022] Open
Abstract
Intravesical bacillus Calmette-Guérin (BCG) is widely used for high-risk, non-muscle-invasive bladder cancer. This report describes four cases that illustrate the spectrum of BCG-induced complications, varying from granulomatous prostatitis to sepsis. There is considerable debate regarding whether inflammation or infection is the predominant mechanism in the pathogenesis of BCG disease. In two patients with a systemic illness, the symptoms first resolved after adding prednisone, indicating a principal role for inflammation in systemic disease. In vitro testing of T-cell responses and a mycobacterial growth inhibition assay were performed for these patients with systemic disease. The patient with mild symptoms showed more effective in vitro growth reduction of BCG, while the patient with sepsis and organ involvement had high T-cell responses but ineffective killing. While these findings are preliminary, it is believed that immunological assays, as described in this report, may provide a better insight into the pathogenesis of BCG disease in individual patients, justifying further research.
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Affiliation(s)
- Manu P Bilsen
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Hanna K de Jong
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Simone A Joosten
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Corine Prins
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jacqueline T Jonker
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob C Pelger
- Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sandra M Arend
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands.
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48
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Dronkers CEA, Klok FA, van Haren GR, Gleditsch J, Westerlund E, Huisman MV, Kroft LJM. Diagnosing upper extremity deep vein thrombosis with non-contrast-enhanced Magnetic Resonance Direct Thrombus Imaging: A pilot study. Thromb Res 2018; 163:47-50. [PMID: 29353683 DOI: 10.1016/j.thromres.2018.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 11/18/2022]
Abstract
Diagnosing upper extremity deep vein thrombosis (UEDVT) can be challenging. Compression ultrasonography is often inconclusive because of overlying anatomic structures that hamper compressing veins. Contrast venography is invasive and has a risk of contrast allergy. Magnetic Resonance Direct Thrombus Imaging (MRDTI) and Three Dimensional Turbo Spin-echo Spectral Attenuated Inversion Recovery (3D TSE-SPAIR) are both non-contrast-enhanced Magnetic Resonance Imaging (MRI) sequences that can visualize a thrombus directly by the visualization of methemoglobin, which is formed in a fresh blood clot. MRDTI has been proven to be accurate in diagnosing deep venous thrombosis (DVT) of the leg. The primary aim of this pilot study was to test the feasibility of diagnosing UEDVT with these MRI techniques. MRDTI and 3D TSE-SPAIR were performed in 3 pilot patients who were already diagnosed with UEDVT by ultrasonography or contrast venography. In all patients, UEDVT diagnosis could be confirmed by MRDTI and 3D TSE-SPAIR in all vein segments. In conclusion, this study showed that non-contrast MRDTI and 3D TSE-SPAIR sequences may be feasible tests to diagnose UEDVT. However diagnostic accuracy and management studies have to be performed before these techniques can be routinely used in clinical practice.
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Affiliation(s)
- C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - G R van Haren
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Gleditsch
- Department of Radiology, Ostfold Hospital Trust, Ostfold, Norway
| | - E Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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49
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Ende-Verhaar YM, Kroft LJM, Mos ICM, Huisman MV, Klok FA. Accuracy and reproducibility of CT right-to-left ventricular diameter measurement in patients with acute pulmonary embolism. PLoS One 2017; 12:e0188862. [PMID: 29182657 PMCID: PMC5705138 DOI: 10.1371/journal.pone.0188862] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/14/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction caused by acute pulmonary embolism (PE) is associated with poor short- and long-term prognosis. RV dilatation as a proxy for RV dysfunction can be assessed by calculating the right-to-left ventricle diameter (RV/LV) ratio on standard computed tomography pulmonary angiography (CTPA) images. It is unknown whether dedicated training is required to accurately and reproducibly measure RV/LV ratio therefore we aimed to assess these parameters in residents in internal medicine without experience in CTPA reading. METHODS CTPA images of 100 patients with PE were assessed by three residents after single instruction, and one experienced thoracic radiologist. Maximum diameters were evaluated in the axial view by measuring the distance between the ventricular endocardium and the interventricular septum, perpendicular to the long axis of the heart. RV dilatation was defined as a ratio of ≥1.0. Interobserver accuracy and reproducibility was determined using Kappa statistics, Bland-Altman analysis and Spearman's rank correlation. RESULTS The kappa statistic for the presence of RV dilatation of the residents compared to the experienced radiologist ranged from 0.83-0.94. The average interobserver difference in calculated RV/LV ratio's (±SD) between the three residents was: -0.01 (SD0.11), 0.07 (SD0.14) and 0.06 (SD0.18) with an overall mean RV/LV diameter ratio of 1.04. In line with this, Spearman's rank correlation coefficients were 0.92, 0.88 and 0.85 respectively indicating very good correlation (p<0.01 for all). CONCLUSION After simple instruction, RV/LV diameter ratio assessment on CTPA images by clinical residents is accurate and reproducible, which is of help in identifying PE patients at risk.
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Affiliation(s)
- Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inge C. M. Mos
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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50
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Klok FA, van der Bijl N, de Roos A, Kroft LJM, Huisman MV, Pasha SM. NT-pro-BNP levels in patients with acute pulmonary embolism are correlated to right but not left ventricular volume and function. Thromb Haemost 2017; 108:367-72. [DOI: 10.1160/th11-12-0901] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 05/09/2012] [Indexed: 11/05/2022]
Abstract
SummaryN-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) is primarily secreted by left ventricular (LV) stretch and wall tension. Notably, NT-pro-BNP is a prognostic marker in acute pulmonary embolism (PE), which primarily stresses the right ventricle (RV). We sought to evaluate the relative contribution of the RV to NT-pro-BNP levels during PE. A posthoc analysis of an observational prospective outcome study in 113 consecutive patients with computed tomography (CT)-proven PE and 226 patients in whom PE was clinically suspected but ruled out by CT. In all patients RV and LV function was established by assessing ECG-triggered-CT measured ventricular end-diastolic-volumes and ejection fraction (EF). NT-pro-BNP was assessed in all patients. The correlation between RV and LV end-diastolic-volumes and systolic function was evaluated by multiple linear regression corrected for known con-founders. In the PE cohort increased RVEF (β-coefficient (95% confidence interval [CI]) –0.044 (± –0.011); p<0.001) and higher RV enddiastolic-volume (β-coefficient 0.005 (± 0.001); p<0.001) were significantly correlated to NT-pro-BNP, while no correlation was found with LVEF ( β-coefficient 0.005 (± 0.010); p=0.587) and LV end-diastolic-volume (β-coefficient –0.003 (± 0.002); p=0.074). In control patients without PE we found a strong correlation between NT-pro-BNP levels and LVEF ( β-coefficient –0.027 (± –0.006); p<0.001) although not LV enddiastolic-volume (β-coefficient 0.001 (± 0.001); p=0.418). RVEF (β-co-efficient –0.002 (± –0.006); p=0.802) and RV end-diastolic-volume (β-coefficient <0.001 (± 0.001); p=0.730) were not correlated in patients without PE. In PE patients, lower RVEF and higher RV end-diastolic-volume were significantly correlated to NT-pro-BNP levels as compared to control patients without PE. These observations provide patho-physiological ground for the well-known prognostic value of NT-pro-BNP in acute PE.
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