Association of right ventricular dysfunction with in-hospital mortality in patients with acute pulmonary embolism and reduction in mortality in patients with right ventricular dysfunction by pulmonary embolectomy

High-Risk Pulmonary Embolism: Embolectomy and Extracorporeal Membrane Oxygenation

Pulmonary embolism (PE) is a common medical condition associated with significant morbidity and mortality. It is the third most common cause of death in the United States. Historically, surgery for PE was associated with a high mortality rate, and this led to a significant decrease in the volume of operations being performed. However, significant improvements in patient selection and outcomes for surgical pulmonary embolectomy (SPE) at the end of the 20th century led to a renewed interest in the procedure. SPE was historically reserved for patients presenting with acute PE and hemodynamic collapse or cardiac arrest. Contemporary data has provided sufficient evidence to support earlier intervention for patients with acute PE who demonstrate clinical, laboratory, and echocardiographic signs of right ventricular dysfunction. Institutions with cardiac surgery capabilities are implementing SPE earlier for the management of both massive and submassive PEs with excellent short-term and long-term outcomes. Recently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been employed successfully to treat patients with massive PE. Excellent short-term outcomes have been reported for patients suffering from PE after treatment with VA-ECMO. Further research, specifically with randomized controlled trials, is needed to determine the appropriate timing and patient selection for the use of VA-ECMO in patients with PE. These data would lead to updated guidelines and algorithms incorporating VA-ECMO and SPE for patients with PE.

Submassive pulmonary embolism

Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.

Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

BACKGROUND

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.

METHODS

Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.

RESULTS

Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018).

CONCLUSIONS

This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Management of massive and submassive pulmonary embolism

Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and submassive pulmonary embolism.

The Swiss cohort of elderly patients with venous thromboembolism (SWITCO65+): rationale and methodology

Venous thromboembolism (VTE) is common and has a high impact on morbidity, mortality, and costs of care. Although most of the patients with VTE are aged ≥65 years, there is little data about the medical outcomes in the elderly with VTE. The Swiss Cohort of Elderly Patients with VTE (SWITCO65+) is a prospective multicenter cohort study of in- and outpatients aged ≥65 years with acute VTE from all five Swiss university and four high-volume non-university hospitals. The goal is to examine which clinical and biological factors and processes of care drive short- and long-term medical outcomes, health-related quality of life, and medical resource utilization in elderly patients with acute VTE. The cohort also includes a large biobank with biological material from each participant. From September 2009 to March 2012, 1,863 elderly patients with VTE were screened and 1003 (53.8%) were enrolled in the cohort. Overall, 51.7% of patients were aged ≥75 years and 52.7% were men. By October 16, 2012, after an average follow-up time of 512 days, 799 (79.7%) patients were still actively participating. SWITCO65+ is a unique opportunity to study short- and long-term outcomes in elderly patients with VTE. The Steering Committee encourages national and international collaborative research projects related to SWITCO65+, including sharing anonymized data and biological samples.

Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis

BACKGROUND

We investigated whether right ventricular dysfunction (RVD) as assessed by echocardiogram can be used as a prognostic factor in hemodynamically stable patients with acute pulmonary embolism (PE). Short-term mortality has been investigated only in small studies and the results have been controversial.

METHODS

A PubMed search was conducted using two keywords, "pulmonary embolism" and "echocardiogram", for articles published between January 1st 1998 and December 31st 2011. Out of 991 articles, after careful review, we found 12 articles that investigated the implications of RVD as assessed by echocardiogram in predicting short-term mortality for hemodynamically stable patients with acute PE. We conducted a meta-analysis of these data to identify whether the presence of RVD increased short-term mortality.

RESULTS

Among 3283 hemodynamically stable patients with acute PE, 1223 patients (37.3%) had RVD, as assessed by echocardiogram, while 2060 patients (62.7%) had normal right ventricular function. Short-term mortality was reported in 167 (13.7%) out of 1223 patients with RVD and in 134 (6.5%) out of 2060 patients without RVD. Hemodynamically stable patients with acute PE who had RVD as assessed by echocardiogram had a 2.29-fold increase in short-term mortality (odds ratio 2.29, 95% confidence interval 1.61-3.26) compared with patients without RVD.

CONCLUSIONS

In hemodynamically stable patients with acute PE, RVD as assessed by echocardiogram increases short-term mortality by 2.29 times. Consideration should be given to obtaining echocardiogram to identify high-risk patients even if they are hemodynamically stable.

Relation of electrocardiographic changes in pulmonary embolism to right ventricular enlargement

The electrocardiographic (ECG) findings in patients with pulmonary embolism (PE) and no previous cardiopulmonary disease are well documented; however, investigation of the relation of ECG abnormalities to right ventricular (RV) enlargement has been limited. The purpose of the present investigation was to assess further the relation of ECG changes in acute PE to RV cavity enlargement (dilation). The records of patients hospitalized from January 2009 to December 2012 with acute PE and no previous cardiopulmonary disease were reviewed. A total of 289 patients were included. RV cavity enlargement was present in 141 patients (49%). Normal ECG findings were less prevalent in patients with PE and RV enlargement than those with PE and no RV enlargement (35 of 141 [25%] vs 56 of 148 [38%]; p = 0.02). One or more of the traditional ECG manifestations of acute cor pulmonale (S1Q3T3, complete right bundle branch block, P pulmonale, or right axis deviation) was found in 18 of 141 patients (13%) with RV enlargement and 13 of 148 (8.8%) with a normal size RV (p = NS). None of the ECG abnormalities was sensitive for RV enlargement. The specificity of P and QRS abnormalities was high. The positive predictive values were ≤83% or had wide 95% confidence intervals. The negative predictive values ranged from 50% to 61%. In conclusion, ECG findings were not useful for the detection or exclusion of RV cavity enlargement in patients with acute PE.

Pig Model of Pulmonary Embolism: Where Is the Hemodynamic Break Point?

Early recognition of collapsing hemodynamics in pulmonary embolism is necessary to avoid cardiac arrest using aggressive medical therapy or mechanical cardiac support. The aim of the study was to identify the maximal acute hemodynamic compensatory steady state. Overall, 40 dynamic obstructions of pulmonary artery were performed and hemodynamic data were collected. Occlusion of only left or right pulmonary artery did not lead to the hemodynamic collapse. When gradually obstructing the bifurcation, the right ventricle end-diastolic area expanded proportionally to pulmonary artery mean pressure from 11.6 (10.1, 14.1) to 17.8 (16.1, 18.8) cm2 (p<0.0001) and pulmonary artery mean pressure increased from 22 (20, 24) to 44 (41, 47) mmHg (p<0.0001) at the point of maximal hemodynamic compensatory steady state. Similarly, mean arterial pressure decreased from 96 (87, 101) to 60 (53, 78) mmHg (p<0.0001), central venous pressure increased from 4 (4, 5) to 7 (6, 8) mmHg (p<0.0001), heart rate increased from 92 (88, 97) to 147 (122, 165) /min (p<0.0001), continuous cardiac output dropped from 5.2 (4.7, 5.8) to 4.3 (3.7, 5.0) l/min (p=0.0023), modified shock index increased from 0.99 (0.81, 1.10) to 2.31 (1.99, 2.72), p<0.0001. In conclusion, instead of continuous cardiac output all of the analyzed parameters can sensitively determine the individual maximal compensatory response to obstructive shock. We assume their monitoring can be used to predict the critical phase of the hemodynamic status in routine practice.

Management of massive and nonmassive pulmonary embolism

Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.

Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

This article addresses the treatment of VTE disease.

METHODS

We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence.

RESULTS

For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C).

CONCLUSION

Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.

Cardiothoracic CT: one-stop-shop procedure? Impact on the management of acute pulmonary embolism

In the treatment of pulmonary embolism (PE) two groups of patients are traditionally identified, namely the hemodynamically stable and instable groups. However, in the large group of normotensive patients with PE, there seems to be a subgroup of patients with an increased risk of an adverse outcome, which might benefit from more aggressive therapy than the current standard therapy with anticoagulants. Risk stratification is a commonly used method to define subgroups of patients with either a high or low risk of an adverse outcome. In this review the clinical parameters and biomarkers of myocardial injury and right ventricular dysfunction (RVD) that have been suggested to play an important role in the risk stratification of PE are described first. Secondly, the use of more direct imaging techniques like echocardiography and CT in the assessment of RVD are discussed, followed by a brief outline of new imaging techniques. Finally, two risk stratification models are proposed, combining the markers of RVD with cardiac biomarkers of ischemia to define whether patients should be admitted to the intensive care unit (ICU) and/or be given thrombolysis, admitted to the medical ward, or be safely treated at home with anticoagulant therapy.

Peripartum pulmonary embolism

Pregnancy is an example of Virchow's triad predisposing to the development of venous thromboembolism (VTE). Specific risk factors for antepartum and postpartum VTE have been identified. The diagnosis of pulmonary embolism in pregnancy is complicated by the physiologic changes of pregnancy as well as physicians' apprehension about ordering radiologic studies during pregnancy because of concerns with fetal well-being. Therapy for VTE is complicated by pregnancy physiology affecting medication pharmacokinetics and bioavailability, and the unpredictable occurrence of labor during therapeutic anticoagulation.

Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association

Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.

Fibrinolysis for acute pulmonary embolism

Acute pulmonary embolism (PE) presents as a constellation of clinical syndromes with a variety of prognostic implications. Patients with acute PE who have normal systemic arterial blood pressure and no evidence of right ventricular (RV) dysfunction have an excellent prognosis with therapeutic anticoagulation alone. Normotensive acute PE patients with evidence of RV dysfunction are categorized as having submassive PE and comprise a population at intermediate risk for adverse events and early mortality. Patients with massive PE present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest and have the highest risk for short-term mortality and adverse events. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Although generally considered to be a life-saving intervention in massive PE, fibrinolysis remains controversial for submassive PE. Successful administration of fibrinolytic therapy requires weighing benefit versus risk. Major bleeding, in particular intracranial hemorrhage, is the most feared complication of fibrinolysis. Alternatives to fibrinolysis for acute PE, including surgical embolectomy, catheter-assisted embolectomy, and inferior vena cava (IVC) filter insertion, should be considered when contraindications exist or when patients have failed to respond to an initial trial of fibrinolytic therapy. Patients with massive and submassive PE may be best served by rapid triage to specialized centers with experience in the administration of fibrinolytic therapy and the capacity to offer alternative advanced therapies such as surgical and catheter-assisted embolectomy.

Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I

Normotensive patients with acute pulmonary embolism (PE) who have increased troponin levels and right ventricular (RV) dysfunction are thought to be at high risk of death, but the level of risk is unclear. We retrospectively evaluated outcome in 1,273 stable patients with PE who had echocardiographic evaluations of RV size and/or measurement of cardiac troponin I (cTnI). In-hospital all-cause mortality was higher in those with RV enlargement (8.0%, 19 of 237, vs 3.3%, 22 of 663, p = 0.003). With an increased cTnI, irrespective of RV enlargement, all-cause mortality was 8.0% (28 of 330) versus 1.9% (15 of 835) in patients with a normal cTnI (p <0.0001). In patients with an increased cTnI combined with an enlarged right ventricle, all-cause mortality was 10.2% (12 of 118) compared to 1.9% (8 of 421) in patients who had neither (p <0.0001). These data show that increased levels of cTnI and RV enlargement are associated with an adverse outcome in stable patients with acute PE. In conclusion, increased levels of cTnI in combination with RV enlargement might indicate a group who would benefit from intense monitoring and aggressive treatment if subsequently indicated. The outcomes, however, were not extreme enough to warrant routine thrombolytic therapy.

Advanced treatment strategies for acute pulmonary embolism, including thrombolysis and embolectomy

The optimal treatment strategy for acute pulmonary embolism relies upon a multidisciplinary team that rapidly assesses available data, performs additional testing if necessary, weighs treatment options, and recommends an appropriate therapeutic plan to the patient and family. Round-the-clock availability is imperative. Centers that specialize in pulmonary embolism management offer a wide range of therapeutic options. Hospitals with more limited facilities should establish pulmonary embolism patient referral and transfer contingency plans that can be activated at a moment's notice. Management options include anticoagulation alone, thrombolysis plus anticoagulation, insertion of an inferior vena caval filter, catheter embolectomy, or surgical embolectomy. The decision-making process requires accurate risk stratification, which is comprised of several crucial components: clinical evaluation that includes history and physical examination, biomarker measurement especially of troponin, as well as assessment of right ventricular size and function based upon chest CT scanning and echocardiography. The 'old school' approach of declaring a benign prognosis based solely upon the presence of normal systemic arterial pressure can delay advanced therapy until after the onset of irreversible cardiogenic shock. We have now formulated a more contemporary, comprehensive, and multifaceted strategy to prognosticate. Our 'new approach' uses advanced treatment strategies in addition to anticoagulation for those pulmonary embolism patients deemed to be at high risk for a poor outcome.

Open pulmonary thromboembolectomy in patients with major pulmonary thromboembolism

PURPOSE

We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism.

MATERIALS AND METHODS

Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest.

RESULTS

There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class.

CONCLUSION

Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.

Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This chapter about treatment for venous thromboembolic disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see "Grades of Recommendation" chapter). Among the key recommendations in this chapter are the following: for patients with objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE), we recommend anticoagulant therapy with subcutaneous (SC) low-molecular-weight heparin (LMWH), monitored IV, or SC unfractionated heparin (UFH), unmonitored weight-based SC UFH, or SC fondaparinux (all Grade 1A). For patients with a high clinical suspicion of DVT or PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). For patients with confirmed PE, we recommend early evaluation of the risks to benefits of thrombolytic therapy (Grade 1C); for those with hemodynamic compromise, we recommend short-course thrombolytic therapy (Grade 1B); and for those with nonmassive PE, we recommend against the use of thrombolytic therapy (Grade 1B). In acute DVT or PE, we recommend initial treatment with LMWH, UFH or fondaparinux for at least 5 days rather than a shorter period (Grade 1C); and initiation of vitamin K antagonists (VKAs) together with LMWH, UFH, or fondaparinux on the first treatment day, and discontinuation of these heparin preparations when the international normalized ratio (INR) is > or = 2.0 for at least 24 h (Grade 1A). For patients with DVT or PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite therapy (Grade 1C). We recommend indefinite anticoagulant therapy for patients with a first unprovoked proximal DVT or PE and a low risk of bleeding when this is consistent with the patient's preference (Grade 1A), and for most patients with a second unprovoked DVT (Grade 1A). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend at least 3 months of treatment with LMWH for patients with VTE and cancer (Grade 1A), followed by treatment with LMWH or VKA as long as the cancer is active (Grade 1C). For prevention of postthrombotic syndrome (PTS) after proximal DVT, we recommend use of an elastic compression stocking (Grade 1A). For DVT of the upper extremity, we recommend similar treatment as for DVT of the leg (Grade 1C). Selected patients with lower-extremity (Grade 2B) and upper-extremity (Grade 2C). DVT may be considered for thrombus removal, generally using catheter-based thrombolytic techniques. For extensive superficial vein thrombosis, we recommend treatment with prophylactic or intermediate doses of LMWH or intermediate doses of UFH for 4 weeks (Grade 1B).

Enlarged right ventricle without shock in acute pulmonary embolism: prognosis

OBJECTIVE

An unsettled issue is the use of thrombolytic agents in patients with acute pulmonary embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement.

METHODS

Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography.

RESULTS

Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk=1.04).

CONCLUSION

In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.

Outcome of pulmonary embolectomy

In view of the importance of pulmonary embolectomy as a possible treatment option in highly compromised patients with acute pulmonary embolism, a systematic review of immediate surgical outcomes was performed. Pooled data from 46 reported case series of patients operated from 1961 to 2006 showed an average mortality of 389 of 1,300 patients (30%). In patients operated on before 1985, the average mortality was 32%, compared with 20% in patients operated from 1985 to 2005. In patients who experienced cardiac arrest before pulmonary embolectomy, the operative mortality was 59% compared with 29% in patients who did not have preoperative cardiac arrest. In conclusion, despite generally high mortality in patients who undergo pulmonary embolectomy, it may have life-saving potential in some instances.

Prediction of Moderate or Severe Pulmonary Hypertension by Main Pulmonary Artery Diameter and Main Pulmonary Artery Diameter/Ascending Aorta Diameter in Pulmonary Embolism

We investigated the accuracy of computed tomographic measurements of main pulmonary artery diameter (MPAD) and of MPAD/ascending aorta diameter (AAD) in predicting moderate or severe pulmonary hypertension in 190 patients with acute pulmonary embolism. A pulmonary artery systolic pressure of > or = 50 mm Hg measured by Doppler echocardiography was considered moderate or severe pulmonary hypertension. A MPAD of > 28.6 mm and a MPAD/AAD ratio of > or = 1.00 measured by computed tomography were considered abnormal. A MPAD of > 28.6 mm had a 75% sensitivity and specificity, a 52% positive predictive value, a 89% negative predictive value, a 3.0 likelihood ratio for a positive test, and a 0.33 likelihood ratio for a negative test in predicting moderate or severe pulmonary hypertension. A MPAD/AAD ratio of > or = 1.00 had a 59% sensitivity, a 82% specificity, a 55% positive predictive value, a 84% negative predictive value, a 3.3 likelihood ratio for a positive test, and a 0.50 likelihood ratio for a negative test.

Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly

BACKGROUND

Acute pulmonary thromboembolism (PTE) can be associated with right ventricular (RV) dysfunction. The relative importance of individual echocardiographic parameters, including those suggesting interdependence between right and left heart chambers, in predicting thromboembolic burden in elderly patients with acute PTE is unknown.

METHODS

We retrospectively studied the transthoracic echocardiograms of 63 elderly patients (age 71 +/- 16 years) with acute PTE, and assessed which individual echocardiographic parameters identified more than 30% pulmonary artery obstruction on the basis of quantitative ventilation/perfusion pulmonary scintigraphy.

RESULTS

RV hypokinesis (visual grade 0-3, P = .02), and the quantitative parameters RV end-systolic area (P = .005) and RV ejection area (P = .01) were associated with more extensive pulmonary artery obstruction. Although right atrial end-systolic area and RV end-diastolic area did not correlate with extent of PTE, the ratio of RV:left ventricular end-diastolic area (P = .003), and ratio of right:left atrial end-systolic area (P = .004), were strongly associated with the extent of pulmonary artery obstruction. These transthoracic echocardiographic parameters were independent of clinical variables such as prior chronic lung disease, congestive cardiac failure, or prior PTE.

CONCLUSION

RV systolic dysfunction, RV end-systolic dilatation, right:left atrial end-systolic area ratio, and RV:left ventricular end-diastolic area ratio correlate with extent of PTE in the elderly.

Electrocardiographic Abnormalities in Patients with Right Ventricular Dilation due to Acute Pulmonary Embolism

In a study of 190 patients with acute pulmonary embolism, right ventricular dilation was present in 64 (34%), mean age 58 +/- 15 years. The 18 electrocardiographic abnormalities on the 12-lead electrocardiogram had a sensitivity of 8-69%, a specificity of 70-98%, a positive predictive value of 23-69%, a negative predictive value of 64-83%, a likelihood ratio for a positive test of 1.3-4.4, and a likelihood ratio for a negative test of 0.41-1.10 in predicting right ventricular dilation in patients with acute pulmonary embolism.

Prognostic value of echocardiography and spiral computed tomography in patients with pulmonary embolism

PURPOSE OF REVIEW

The identification of patients with pulmonary embolism who are at risk for mortality or severe morbidity in the early observation period is important because these patients may benefit from more aggressive initial treatment such as thrombolysis or catheter removal of the thrombus. Right ventricular dysfunction has been suggested to have a prognostic value for the occurrence of these adverse outcomes. The purpose of this review is to determine the prevalence and prognostic value of right ventricular dysfunction, in particular in normotensive patients with pulmonary embolism. The association between right ventricular dysfunction and outcome of pulmonary embolism was evaluated for studies using echocardiography, spiral computed tomography, or both to detect right ventricular dysfunction.

RECENT FINDINGS

Seven studies using echocardiography with a total of 3468 patients and six studies using spiral computed tomography with a total of 868 patients were identified. The prevalence of right ventricular dysfunction with echocardiography in normotensive patients was approximately 30 to 40%, with a positive predictive value for short-term mortality of approximately 5%. These indices could not be calculated for normotensive patients in the studies that used spiral computed tomography.

SUMMARY

The studies using echocardiography show that there is an association between right ventricular dysfunction and prognosis of pulmonary embolism in normotensive patients. Whether this is clinically useful in guiding more aggressive therapy remains to be determined, however. Thus far, the results of the studies with spiral computed tomography are too preliminary to enable definite conclusions to be drawn for the normotensive patient group.