CT signs of right ventricular dysfunction: prognostic role in acute pulmonary embolism

Alterations and Significance of Computed Tomography Pulmonary Angiography-Derived Parameters in Older Patients With Acute Pulmonary Embolism

OBJECTIVE

This study aimed to investigate changes of computed tomography pulmonary angiography (CTPA)-derived parameters in older adults with acute pulmonary embolism (APE).

METHODS

According to the pulmonary artery obstruction index (PAOI), patients with APE were divided into the A1 (PAOI ≥30%, n = 57) and A2 (PAOI <30%, n = 40) groups. Participants without APE were placed in group B (n = 170). The left atrial (LA) and left ventricular (LV) parameters among the three groups were compared, and the parameter changes in the 44 patients with APE were analyzed before and after treatment. The correlation between APE severity and the parameters was analyzed using correlation analysis.

RESULTS

The left-to-right diameters (LR) of LA, and LR × anteroposterior diameters (AP) of LA and LV: A1 < A2 < B; LR of LV: A1 < A2, B; AP of LA and LV: A1, A2 < B. After treatment, LR and LR × AP of the LA and LV were significantly increased in the group A1 and LR of the LV and LR × AP of the LA and LV were elevated in the group A2. Acute pulmonary embolism severity was closely associated with LR × AP ( r = -0.557) and LR ( r = -0.477) of LA.

CONCLUSIONS

With an increase in the degree of obstruction, older adults had a smaller LA and LV. Furthermore, the LR and LR × AP values of the LA were significantly decreased. These results contribute to in-time risk stratification.

Minimizing Contrast Media Dose in CT Pulmonary Angiography with Clinical Photon Counting Using High Pitch Technique

RATIONALE AND OBJECTIVES

To evaluate the potential to reduce the amount of iodinated contrast media (CM) for computer tomographic pulmonary angiography (CTPA) with a novel photon-counting-detector CT (PCCT).

MATERIALS AND METHODS

Overall, 105 patients referred for CTPA were retrospectively included in this study. CTPA was performed using bolus tracking and high-pitch dual-source scanning (FLASH mode) on a novel PCCT (Naeotom Alpha, Siemens Healthineers). CM (Accupaque 300, GE Healthcare) dose was lowered stepwise following the introduction of the new CT scanner. Thus, patients could be divided into 3 groups as follows: group 1, n = 29, 35 ml of CM; group 2, n = 62, 45 ml of CM and group 3, n = 14, 60 ml of CM. Four readers independently assessed the image quality (Likert-scale 1-5) and adequate assessment of the segmental pulmonary arteries. Additionally, the pulmonary arterial contrast opacification was measured.

RESULTS

The subjective image quality was rated highest in group 1 with 4.6 compared to 4.5 (group 2) and 4.1 (group 3) with a significant difference between groups 1 and 3 (p < 0.001) and between groups 2 and 3 (p = 0.003). In all groups, almost all segmental pulmonary arteries could be assessed adequately without significant differences (18.5 vs. 18.7 vs. 18.4). Mean attenuation in the pulmonary trunk did not differ significantly between groups 321 ± 92 HU versus 345 ± 93 HU versus 347 ± 88 HU (p = 0.69).

CONCLUSION

Significant CM dose reduction is possible without a reduction in image quality. PCCT enables diagnostic CTPA with 35 ml of CM.

Automated detection, segmentation and measurement of major vessels and the trachea in CT pulmonary angiography

Mediastinal structure measurements are important for the radiologist's review of computed tomography pulmonary angiography (CTPA) examinations. In the reporting process, radiologists make measurements of diameters, volumes, and organ densities for image quality assessment and risk stratification. However, manual measurement of these features is time consuming. Here, we sought to develop a time-saving automated algorithm that can accurately detect, segment and measure mediastinal structures in routine clinical CTPA examinations. In this study, 700 CTPA examinations collected and annotated. Of these, a training set of 180 examinations were used to develop a fully automated deterministic algorithm. On the test set of 520 examinations, two radiologists validated the detection and segmentation performance quantitatively, and ground truth was annotated to validate the measurement performance. External validation was performed in 47 CTPAs from two independent datasets. The system had 86-100% detection and segmentation accuracy in the different tasks. The automatic measurements correlated well to those of the radiologist (Pearson's r 0.68-0.99). Taken together, the fully automated algorithm accurately detected, segmented, and measured mediastinal structures in routine CTPA examinations having an adequate representation of common artifacts and medical conditions.

Advances for Pulmonary Functional Imaging: Dual-Energy Computed Tomography for Pulmonary Functional Imaging

Dual-energy computed tomography (DECT) can improve the differentiation of material by using two different X-ray energy spectra, and may provide new imaging techniques to diagnostic radiology to overcome the limitations of conventional CT in characterizing tissue. Some techniques have used dual-energy imaging, which mainly includes dual-sourced, rapid kVp switching, dual-layer detectors, and split-filter imaging. In iodine images, images of the lung's perfused blood volume (PBV) based on DECT have been applied in patients with pulmonary embolism to obtain both images of the PE occluding the pulmonary artery and the consequent perfusion defects in the lung's parenchyma. PBV images of the lung also have the potential to indicate the severity of PE, including chronic thromboembolic pulmonary hypertension. Virtual monochromatic imaging can improve the accuracy of diagnosing pulmonary vascular diseases by optimizing kiloelectronvolt settings for various purposes. Iodine images also could provide a new approach in the area of thoracic oncology, for example, for the characterization of pulmonary nodules and mediastinal lymph nodes. DECT-based lung ventilation imaging is also available with noble gases with high atomic numbers, such as xenon, which is similar to iodine. A ventilation map of the lung can be used to image various pulmonary diseases such as chronic obstructive pulmonary disease.

Clinical predictors and outcomes of pulmonary infarction in patients with central pulmonary embolism

BACKGROUND

Given the heterogeneity of predisposing factors associated with pulmonary infarction (PI) and the lack of clinically relevant outcomes among patients with acute pulmonary embolism (PE) complicated by PI, further investigation is required.

METHODS

Retrospective study of patients with central PE in an 11-year period. Data were stratified according to the diagnosis of PI. Multivariable logistic regression analysis was used to analyze factors associated with PI development and determine if PI was associated with severe hypoxemic respiratory failure and mechanical ventilation use.

RESULTS

Of 645 patients with central PE, 24% (n = 156) had PI. After adjusting for demographics, comorbidities, and clinical features on admission, only age (OR 0.98, CI 0.96-0.99; p = 0.008) was independently associated with PI. Regarding outcomes, 35% (n = 55) had severe hypoxemic respiratory failure, and 19% (n = 29) required mechanical ventilation. After adjusting for demographics, PE severity, and right ventricular dysfunction, PI was independently associated with severe hypoxemic respiratory failure (OR 1.78; CI 1.18-2.69, p = 0.005) and mechanical ventilation (OR 1.92; CI 1.14-3.22, p = 0.013).

CONCLUSIONS

Aging is a protective factor against PI. In acute central PE, subjects with PI had higher odds of developing severe hypoxemic respiratory failure and requiring mechanical ventilation.

Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis

BACKGROUND

In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE.

METHODS

Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality.

RESULTS

A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes.

CONCLUSION

Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Cardiac Imaging Biomarkers in Chronic Kidney Disease

Uremic cardiomyopathy (UC), the peculiar cardiac remodeling secondary to the systemic effects of renal dysfunction, is characterized by left ventricular (LV) diffuse fibrosis with hypertrophy (LVH) and stiffness and the development of heart failure and increased rates of cardiovascular mortality. Several imaging modalities can be used to obtain a non-invasive assessment of UC by different imaging biomarkers, which is the focus of the present review. Echocardiography has been largely employed in recent decades, especially for the determination of LVH by 2-dimensional imaging and diastolic dysfunction by pulsed-wave and tissue Doppler, where it retains a robust prognostic value; more recent techniques include parametric assessment of cardiac deformation by speckle tracking echocardiography and the use of 3D-imaging. Cardiac magnetic resonance (CMR) imaging allows a more accurate assessment of cardiac dimensions, including the right heart, and deformation by feature-tracking imaging; however, the most evident added value of CMR remains tissue characterization. T1 mapping demonstrated diffuse fibrosis in CKD patients, increasing with the worsening of renal disease and evident even in early stages of the disease, with few, but emerging, prognostic data. Some studies using T2 mapping highlighted the presence of subtle, diffuse myocardial edema. Finally, computed tomography, though rarely used to specifically assess UC, might provide incidental findings carrying prognostic relevance, including information on cardiac and vascular calcification. In summary, non-invasive cardiovascular imaging provides a wealth of imaging biomarkers for the characterization and risk-stratification of UC; integrating results from different imaging techniques can aid a better understanding of the physiopathology of UC and improve the clinical management of patients with CKD.

[Modern imaging of the pulmonary hilum : Anatomy, pathologies, pitfalls]

BACKGROUND

Modern medical imaging is a key component of efficient in- and out-patient precision medicine. Conventional radiography and computer tomography scans (CT) are among the most frequent radiologic exams. Medical imaging plays a key role in target-oriented medicine.

OBJECTIVES

The purpose of this article is to review the anatomy of the hilum of the lung and its most frequent associated pathologies since it is an important gateway of elementary structures of the thorax. Important signs and patterns for image interpretation in different modalities are also reviewed.

RESULTS

Thorough knowledge of anatomy, signs, and patterns of pathologies especially in conventional radiography and pitfalls of the more sensitive cross-sectional imaging is essential to support target-oriented patient care.

CONCLUSION

Conventional radiography is affordable and readily available. It is very suitable for pathology screening, i.e., at the hilum of the lung. Cross-sectional imaging specifies diagnostics due to superior anatomic discrimination.

Quantitative analysis of pulmonary perfusion with dual-energy CT angiography: comparison of two quantification methods in patients with pulmonary embolism

The study aimed to evaluate a quantification method of pulmonary perfusion with Dual-Energy CT Angiography (DE-CTA) normalized by lung density in the prediction of outcome in acute pulmonary embolism (PE). In this prospective study with CTA scans acquired with different breathing protocols, two perfusion parameters were calculated: %PBV (relative value of PBV, expressed per unit volume) and PBVm (PBV normalized by lung density, expressed per unit mass). DE-CTA parameters were correlated with simplified pulmonary embolism severity index (sPESI) and with outcome groups, alone and in combinationwith tomographic right-to-left ventricular ratios (RV/LV). PBVm showed significant correlation with sPESI. PBVm presented higher accuracy than %PBV In the prediction of ICU admission or death in patients with PE, with the best performance when combined with RV/LV volumetric ratio.

Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism

OBJECTIVES

There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE).

METHODS

On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.

RESULTS

Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients.

CONCLUSION

A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.

Imaging in the Intensive Care Unit

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Computed tomography and magnetic resonance imaging for pulmonary embolus evaluation in children: up-to-date review on practical imaging protocols

Pulmonary embolism (PE) is a potentially life-threatening condition that requires immediate medical intervention. Although PE was previously thought to occur infrequently in the pediatric population, recent studies have found a higher-than-expected prevalence of PE in the pediatric population of up to 15.5%. The imaging modality of choice for detecting PE in the pediatric population is multi-detector CT angiography, although MRI is assuming a growing and more important role as a potential alternative modality. Given the recent advances in both computed tomography pulmonary angiography (CTPA) and MRI techniques, a growing population of pediatric patients with complex comorbidities (such as children with a history of surgeries for congenital heart disease repair), and the recent waves of coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C), which are associated with increased risk of PE, there is new and increased need for an up-to-date review of practical CT and MRI protocols for PE evaluation in children. This article provides guidance for up-to-date CT and MR imaging techniques, reviews key recent studies on the imaging of pediatric PE, and discusses relevant pediatric PE imaging pearls and pitfalls, in hopes of providing readers with up-to-date and accurate practice for imaging evaluation of PE in children.

Cardiovascular findings on chest computed tomography associated with COVID-19 adverse clinical outcomes

STUDY OBJECTIVE

Chest computed tomography (chest CT) is routinely obtained to assess disease severity in COVID-19. While pulmonary findings are well-described in COVID-19, the implications of cardiovascular findings are less well understood. We evaluated the impact of cardiovascular findings on chest CT on the adverse composite outcome (ACO) of hospitalized COVID-19 patients.

SETTING/PARTICIPANTS

245 COVID-19 patients who underwent chest CT at Rush University Health System were included.

DESIGN

Cardiovascular findings, including coronary artery calcification (CAC), aortic calcification, signs of right ventricular strain [right ventricular to left ventricular diameter ratio, pulmonary artery to aorta diameter ratio, interventricular septal position, and inferior vena cava (IVC) reflux], were measured by trained physicians.

INTERVENTIONS/MAIN OUTCOME MEASURES

These findings, along with pulmonary findings, were analyzed using univariable logistic analysis to determine the risk of ACO defined as intensive care admission, need for non-invasive positive pressure ventilation, intubation, in-hospital and 60-day mortality. Secondary endpoints included individual components of the ACO.

RESULTS

Aortic calcification was independently associated with an increased risk of the ACO (odds ratio 1.86, 95% confidence interval (1.11-3.17) p < 0.05). Aortic calcification, CAC, abnormal septal position, or IVC reflux of contrast were all significantly associated with 60-day mortality and major adverse cardiovascular events. IVC reflux was associated with in-hospital mortality (p = 0.005).

CONCLUSION

Incidental cardiovascular findings on chest CT are clinically important imaging markers in COVID-19. It is important to ascertain and routinely report cardiovascular findings on CT imaging of COVID-19 patients as they have potential to identify high risk patients.

The mean bilateral proximal extension of the clot is associated with pulmonary embolism severity parameters and management-associated outcomes

BACKGROUND

The value of the proximal extension of the clot in risk stratification of pulmonary embolism (PE) has not been established. The mean bilateral proximal extension of the clot (MBPEC) is a computed tomography (CT) radiological score, where initial evaluation showed promising results considering its ability in predicting the severity of PE.

PURPOSE

To explore the possible associations between MBPEC and PE-severity parameters, short- and long-term outcomes of PE, and inter-observer agreement.

MATERIAL AND METHODS

Patients diagnosed with PE at Østfold Hospital, Norway during 2003-2011 were identified. MBPEC was calculated by calculating the mean of a score in the range of 1-4 assigned for the most proximal extension of the clot in each lung: sub-segmental; segmental; lobar; and main pulmonary arteries. Medical records were reviewed to capture clinical, biochemical, and management-associated data (thrombolysis, admission to ICU).

RESULTS

The mean age of 245 included patients was 55 ± 16 years; 42% were women. Patients with higher MBPEC scores had a significantly higher pulse rate and lower oxygen saturation. MBPEC score <4 predicted a negative troponin value with a negative predictive value of 90% (95% confidence interval [CI] 81-95). Patients with MBPEC 4 were 5.3 times more likely to have elevated troponin (odds ratio [OR] 5.3, 95% CI 2.0-14.3). MBPEC score of 4 was independently associated with admission to ICU (OR 3.8, 95% CI 1.8-7.9). The inter-observer agreement was excellent; weighted kappa 0.82.

CONCLUSION

MBPEC is associated with PE-severity parameters and can predict short-term adverse outcomes.

Dual-Energy CT for Pulmonary Embolism: Current and Evolving Clinical Applications

Pulmonary embolism (PE) is a potentially fatal disease if the diagnosis or treatment is delayed. Currently, multidetector computed tomography (MDCT) is considered the standard imaging method for diagnosing PE. Dual-energy CT (DECT) has the advantages of MDCT and can provide functional information for patients with PE. The aim of this review is to present the potential clinical applications of DECT in PE, focusing on the diagnosis and risk stratification of PE.

Correlation between CT-derived cardiac chamber volume, myocardial injury and mortality in acute pulmonary embolism

INTRODUCTION

The release of troponin in patients with acute pulmonary embolism (PE) is assumed to be secondary to elevated intracardiac chamber pressure. Since right ventricular (RV) hypertrophy does not develop in the acute setting, pressure overload correlates with chamber dilatation, causing myocardial injury. The aim of the present study was to investigate correlations between cardiac chamber volume, troponin and subsequent early mortality in patients with acute PE and refine risk stratification.

MATERIALS AND METHODS

Patients who underwent a computerized tomographic pulmonary angiogram (CTPA) and a troponin test within 24 h of the CTPA were included. Automated software calculated the volumes of the four cardiac chambers indexed to body surface area (BSA) and correlated them to troponin and early all-cause mortality.

RESULTS

The final cohort consisted of 370 patients (56% females) with acute PE. RV volume and right to left ventricular volume ratio (VVR) were the most significant indicators for elevated troponin (receiving operating characteristic [ROC] 0.796, confidence interval [CI]: 0.749-0.843, p < 0.001, and ROC 0.802, CI: 0.753-0.851, p < 0.001, respectively). VVR cutoff values, which are predictive of elevated troponins, correlated with higher 30-day mortality (odds ratio = 3.1, CI 1.5-6.7, p = 0.003) for a VVR >3 compared to a VVR <2.

CONCLUSION

Cardiac chamber volume correlates to elevated troponin in patients with acute PE. A higher VVR reflects an increased likelihood for myocardial ischemia, as well as an increased short-term mortality risk. These data are available seconds after CTPA performance and may contribute to refining patients' risk stratification.

Morphological Analysis of the Right Ventricular Endocardial Wall in Pulmonary Hypertension

Pulmonary hypertension (PH) is a chronic progressive disease diagnosed when the pressure in the main pulmonary artery, assessed by right heart catheterization (RHC), is greater than 25 mmHg. Changes in the pulmonary vasculature due to the high pressure yield an increase in the right ventricle (RV) afterload. This starts a remodeling process during which the ventricle exhibits changes in shape and eventually fails. RV models were obtained from the segmentation of cardiac magnetic resonance images at baseline and 1-year follow-up for a pilot study that involved 12 PH and 7 control subjects. The models were used to create surface meshes of the geometry and to compute the principal, mean, and Gaussian curvatures. Ten global curvature indices were calculated for each of the RV endocardial wall reconstructions at the end-diastolic volume (EDV) and end-systolic volume (ESV) phases of the cardiac cycle. Statistical analysis of the data was performed to discern if there are significant differences in the curvature indices between controls and the PH group, as well as between the baseline and follow-up phases for the PH subjects. Six curvature indices, namely, the Gaussian curvature at ESV, the mean curvature at EDV and ESV, the L2-norm of the mean curvature at ESV, and the L2-norm of the major principal curvature at EDV and ESV, were found to be significantly different between controls and PH subjects (p < 0.05). We infer that these geometry measures could be used as indicators of RV endocardial wall morphology changes. Two global parameters, the Gaussian and mean curvatures at ESV, showed significant changes at the one-year follow-up for the PH subjects (p < 0.05). The aforementioned geometry measures to assess changes in RV shape could be used as part of a noninvasive computational tool to aid clinicians in PH diagnostic and progression assessment, and to evaluate the effectiveness of treatment.

Rapid prediction of deterioration risk among non-high-risk patients with acute pulmonary embolism at admission: An imaging tool

BACKGROUND

Computed tomography (CT) pulmonary angiography as the first-line diagnosis tool of acute pulmonary embolism (PE), might improve this discriminatory power. We aimed to developed a simply tool combining multi-CT parameters to complete individualized risk assessment of deterioration in non-high-risk patients with acute PE at admission.

METHOD

Consecutive non-high-risk patients with acute PE who were treated in a Chinese center during 2010-2021, were collected.Prognosis-related CT parameters were reviewed. Deterioration was defined as any adverse event within 30 day after admission. Eligible patients were randomized into derivation and validation cohorts. In the derivation cohort, CT parameters were screened for importance using classification tree methodology and enrolled variables was partitioned via curve-fitting and dose-response analysis. A nomogram was developed and the predictive power in both cohorts was evaluated based on the area under the receiver operating characteristic curve (AUROC) and the corresponding 95% confidence interval (CI).

RESULT

A total of 1001 patients were included. The preliminary analyses revealed that deterioration risk was related to the right-to-left ventricular diameter ratio at 4-chamber view, pulmonary vein filling abnormality. After a curve-fitting to deterioration risk, these parameters were partitioned and used to develop a nomogram, which had AUROC values of 0.91 (95% CI: 0.87-0.96) in the derivation cohort and 0.89 (95% CI: 0.81-0.97) in the validation cohort. A web-based version of the radiomics scoring tool was published online for use in clinical practice (https://acutepeprediction.shinyapps.io/Radiomics_Predictive_Tool/).

CONCLUSION

This simply tool can complete rapid estimation of deterioration risk among non-high-risk acute PE patients at admission.

Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism

OBJECTIVES

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.

METHODS

This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.

RESULTS

The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.

CONCLUSION

CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Left atrial size measured on CT pulmonary angiography: another parameter of pulmonary embolism severity? A systematic review

We systematically review the potential role of left atrial (LA) size, evaluated at computed tomography angiography (CTA) in patients with acute pulmonary embolism (PE), as a new parameter of PE severity. A literature search based on PubMed (MEDLINE), Scopus, Cochrane library and Google Scholar databases was performed to locate previous published investigations reporting data on the severity of acute PE based on the evaluation of LA size (either volume, diameter or area). Six studies, corresponding to a total of 990 patients, published between 2012 and 2019 were included into the analysis. The severity of acute PE, in terms of hemodynamic impairment, increases with the reduction of the LA volume and a significant negative correlation was observed between the pulmonary artery obstruction index (PAOI) and the LA area. Similarly, the longest left-to-right as well as the anteroposterior diameters of the LA had a significant positive correlation with the PAOI index for both the measurement. The LA volume significantly decreased with the increasing of the PAOI index. Moreover, a lower LA volume was observed in those subjects with a saddle PE appearing as the best single parameter able to discriminate between patients having or not a saddle acute PE. Intriguingly, PE patients died within 30 days from the acute event had a significant small LA volume compared to survivors. Data obtained from the current medical literature seem to suggest that the evaluation of LA size evaluation could be a new parameter of PE severity. Further and larger prospective studies are needed to confirm preliminary findings.

Importance of computed tomography pulmonary angiography for predict 30-day mortality in acute pulmonary embolism patients

•

The study provides a cut-off value of RV diameter and CT obstruction index by CTPA to predict acute PE patients' mortality.

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RV diameter of 53 mm or over and CT obstruction index >70 % is associated with increased 30-day mortality in APE patients.

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Increased RV diameter by CTPA is a better predictor of mortality than the clinical Pulmonary Embolism Severity Index (PESI).

•

CTPA can be valuable as both the diagnostic and prognostic tool in APE patients.

Objective

The purpose of the present study was to assess the implications of different parameters of computed tomography pulmonary angiography (CTPA) to predict 30-day mortality in acute pulmonary embolism (APE) patients.

Material and Method

Patients who had clinical suspicion of APE and underwent CTPA were recruited in a retrospective cohort study. The findings of the CTPA included the parameters of right ventricular dysfunction (RVD), the severity of obstruction to the pulmonary artery by CT obstruction index, and the ratio of pulmonary trunk diameter and aorta. The endpoint of the study was established as the 30-day mortality associated with APE.

Results

A total of 238 patients with a confirmed APE diagnosis with CTPA were included in the study; 26 (10.9 %) of those patients died within 30 days. In patients with cancer and the Pulmonary Embolism Severity Index (PESI) class 5, the mortality rate was significantly higher. Compared with survivors, the mean CT obstruction index in the non-survivor group was significantly higher (p < 0.001). Higher mortality was associated with all RVD parameters identified by CTPA, such as the RV/LV ratio (p < 0.001), interventricular septum deviation grade 3 (p < 0.001), increased RV diameter (p < 0.001), and IVC contrast reflux (p < 0.001). The highest adjusted odds ratio was RV diameter at 1.094, followed by PESI and the CT obstruction index at 1.040.

Conclusion

CTPA-detected RVD parameters and CT obstruction index can predict a 30-day mortality rate in APE patients and be used for risk stratification. In APE patients, the RV diameter of 53 mm or greater and the CT obstruction index >70% is associated with increased 30-day mortality.

Assessment of Right Ventricular Function With CT and Echocardiography in Patients With Severe Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation

Supplemental Digital Content is available in the text.

Changes in right ventricular size and function are frequently observed in patients with severe acute respiratory distress syndrome. The majority of patients who receive venovenous extracorporeal membrane oxygenation undergo chest CT and transthoracic echocardiography. The aims of this study were to compare the use of CT and transthoracic echocardiography to evaluate the right ventricular function and to determine the prevalence of acute cor pulmonale in this patient population.

Evaluating the Right Ventricle in Acute and Chronic Pulmonary Embolism: Current and Future Considerations

The right ventricle (RV), due to its morphologic and physiologic differences, is susceptible to sudden increase in RV afterload, as noted in patients with acute pulmonary embolism (PE). Functional impairment of RV function is a stronger presage of adverse outcomes in acute PE than the location or burden of emboli. While current iterations of most clinical prognostic scores do not incorporate RV dysfunction, advancements in imaging have enabled more granular and accurate assessment of RV dysfunction in acute PE. RV enlargement and dysfunction on imaging is noted only in a subset of patients with acute PE and is dependent on underlying cardiopulmonary reserve and clot burden. Specific signs like McConnell's and "60/60" sign are noted in less than 20% of patients with acute PE. About 2% of patients with acute PE develop chronic thromboembolic pulmonary hypertension, characterized by continued deterioration in RV function in a subset of patients with a continuum of RV function from preserved to overt right heart failure. Advances in molecular and other imaging will help better characterize RV dysfunction in this population and evaluate the response to therapies.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

Background

It is important to identify deterioration in normotensive patients with acute pulmonary embolism (PE). This study aimed to develop a tool for predicting deterioration among normotensive patients with acute PE on admission.

Methods

Clinical, laboratory, and computed tomography parameters were retrospectively collected for normotensive patients with acute PE who were treated at a Chinese center from January 2011 to May 2020 on admission into the hospital. The endpoint of the deterioration was any adverse outcome within 30 days. Eligible patients were randomized 2:1 to derivation and validation cohorts, and a nomogram was developed and validated by the aforementioned cohorts, respectively. The areas under the curves (AUCs) with 95% confidence intervals (CIs) were calculated. A risk-scoring tool for predicting deterioration was applied as a web-based calculator.

Results

The 845 eligible patients (420 men, 425 women) had an average age of 60.05 ± 15.43 years. Adverse outcomes were identified for 81 patients (9.6%). The nomogram for adverse outcomes included heart rate, systolic pressure, N-terminal-pro brain natriuretic peptide, and ventricle/atrial diameter ratios at 4-chamber view, which provided AUC values of 0.925 in the derivation cohort (95% CI 0.900–0.946, p < 0.001) and 0.900 in the validation cohort (95% CI 0.883–0.948, p < 0.001). A risk-scoring tool was published as a web-based calculator (https://gaoyzcmu.shinyapps.io/APE9AD/).

Conclusions

We developed a web-based scoring tool that may help predict deterioration in normotensive patients with acute PE.

Regional shape, global function and mechanics in right ventricular volume and pressure overload conditions: a three-dimensional echocardiography study

Our aim was to assess the regional right ventricular (RV) shape changes in pressure and volume overload conditions and their relations with RV function and mechanics. The end-diastolic and end-systolic RV endocardial surfaces were analyzed with three-dimensional echocardiography (3DE) in 33 patients with RV volume overload (rToF), 31 patients with RV pressure overload (PH), and 60 controls. The mean curvature of the RV inflow (RVIT) and outflow (RVOT) tracts, RV apex and body (both divided into free wall (FW) and septum) were measured. Zero curvature defined a flat surface, whereas positive or negative curvature indicated convexity or concavity, respectively. The longitudinal and radial RV wall motions were also obtained. rToF and PH patients had flatter FW (body and apex) and RVIT, more convex interventricular septum (body and apex) and RVOT than controls. rToF demonstrated a less bulging interventricular septum at end-systole than PH patients, resulting in a more convex shape of the RVFW (r = − 0.701, p < 0.0001), and worse RV longitudinal contraction (r = − 0.397, p = 0.02). PH patients showed flatter RVFW apex at end-systole compared to rToF (p < 0.01). In both groups, a flatter RVFW apex was associated with worse radial RV contraction (r = 0.362 in rToF, r = 0.482 in PH at end-diastole, and r = 0.555 in rToF, r = 0.379 in PH at end-systole, respectively). In PH group, the impairment of radial contraction was also related to flatter RVIT (r = 0.407) and more convex RVOT (r = − 0.525) at end-systole (p < 0.05). In conclusion, different loading conditions are associated to specific RV curvature changes, that are related to longitudinal and radial RV dysfunction.

Pulmonary embolisms in patients with COVID-19: A prevalence study in a tertiary hospital

Introduction

Objective

Methods

Results

Conclusions

Prognostic Value of Dual-Energy CT-Based Iodine Quantification versus Conventional CT in Acute Pulmonary Embolism: A Propensity-Match Analysis

Objective

The present study aimed to investigate whether quantitative dual-energy computed tomography (DECT) parameters offer an incremental risk stratification benefit over the CT ventricular diameter ratio in patients with acute pulmonary embolism (PE) by using propensity score analysis.

Materials and Methods

This study was conducted on 480 patients with acute PE who underwent CT pulmonary angiography (CTPA) or DECT pulmonary angiography (DE CT-PA). This propensity-matched study population included 240 patients with acute PE each in the CTPA and DECT groups. Altogether, 260 (54.1%) patients were men, and the mean age was 64.9 years (64.9 ± 13.5 years). The primary endpoint was all-cause death within 30 days. The Cox proportional hazards regression model was used to identify associations between CT parameters and outcomes and to identify potential predictors. Concordance (C) statistics were used to compare the prognoses between the two groups.

Results

In both CTPA and DECT groups, right to left ventricle diameter ratio ≥ 1 was associated with an increased risk of all-cause death within 30 days (hazard ratio: 3.707, p < 0.001 and 5.573, p < 0.001, respectively). However, C-statistics showed no statistically significant difference between the CTPA and DECT groups for predicting death within 30 days (C-statistics: 0.759 vs. 0.819, p = 0.117).

Conclusion

Quantitative measurement of lung perfusion defect volume by DECT had no added benefit over CT ventricular diameter ratio for predicting all-cause death within 30 days.

Pulmonary embolisms in patients with COVID-19: a prevalence study in a tertiary hospital

INTRODUCTION

SARS-CoV-2, the virus responsible for the current pandemic, predominantly affects the respiratory tract, and a growing number of publications report the predisposition of patients with COVID-19 to develop thrombotic phenomena.

OBJECTIVE

To determine the prevalence of pulmonary embolism in patients with COVID-19; to determine the possible relationship between the severity of pulmonary involvement and D-dimer levels; to analyze the location of pulmonary embolisms in patients with COVID-19 and to compare it with the location in patients without COVID-19.

METHODS

This retrospective study analyzed all CT angiograms of the pulmonary arteries done in patients with suspected pulmonary embolisms between March 15 and April 30, 2020 and compared them with studies done in the same period one year earlier.

RESULTS

We included 492 pulmonary CT angiograms (342 (69.9%) in patients with COVID-19 and 147 (30.1%) in patients without COVID-19). The prevalence of pulmonary embolisms was higher in patients with COVID-19 (26% vs. 16.3% in patients without COVID-19, p=0.0197; relative risk=1.6). The prevalence of pulmonary embolisms in the same period in 2019 was 13.2%, similar to that of the group of COVID-19-negative patients in 2020 (p=0.43). There were no significant differences in D-dimer levels or the location of pulmonary embolisms between the two groups. CT showed moderate or severe pulmonary involvement in 78.7% of the patients with COVID-19.

CONCLUSIONS

Patients with COVID-19 have an increased prevalence of pulmonary embolisms (26%), and most (78.7%) have moderate or severe lung involvement on CT studies. The location of pulmonary embolisms and the degree of elevation of D-dimer levels does not differ between patients with COVID-19 and those without.

Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography

OBJECTIVE

To evaluate the relation of coronary artery calcifications (CAC) on non-ECG-gated CT pulmonary angiography (CTPA) with short-term mortality in patients with acute pulmonary embolism (PE).

METHODS

We retrospectively included all in-patients between May 2007 and December 2014 with an ICD-9 code for acute PE and CTPA and transthoracic echocardiography available. CAC was qualitatively graded as absent, mild, moderate, or severe. Relations of CAC with overall and PE-related 30-day mortality were assessed using logistic regression analyses. The independence of those relations was assessed using a nested approach, first adjusting for age and gender, then for RV strain, peak troponin T, and cardiovascular risk factors for an overall model.

RESULTS

Four hundred seventy-nine patients were included (63 ± 16 years, 52.8% women, 47.2% men). In total, 253 (52.8%) had CAC-mild: 143 (29.9%); moderate: 89 (18.6%); severe: 21 (4.4%). Overall mortality was 8.8% (n = 42) with higher mortality with any CAC (12.6% vs. 4.4% without; odds ratio [OR] 3.1 [95%CI 2.1-14.5]; p = 0.002). Mortality with severe (19.0%; OR 5.1 [95%CI 1.4-17.9]; p = 0.011), moderate (11.2%; OR 2.7 [95%CI 1.1-6.8]; p = 0.031), and mild CAC (12.6%; OR 3.1 [95%CI 1.4-6.9]; p = 0.006) was higher than without. OR adjusted for age and gender was 2.7 (95%CI 1.0-7.1; p = 0.050) and 2.6 (95%CI 0.9-7.1; p = 0.069) for the overall model. PE-related mortality was 4.0% (n = 19) with higher mortality with any CAC (5.9% vs. 1.8% without; OR 3.5 [95%CI 1.1-10.7]; p = 0.028). PE-related mortality with severe CAC was 9.5% (OR 5.8 [95%CI 1.0-34.0]; p = 0.049), with moderate CAC 6.7% (OR 4.0 [95%CI 1.1-14.6]; p = 0.033), and with mild 4.9% (OR 2.9 [95%CI 0.8-9.9]; p = 0.099). OR adjusted for age and gender was 4.2 (95%CI 0.9-20.7; p = 0.074) and 3.4 (95%CI 0.7-17.4; p = 0.141) for the overall model. Patients with sub-massive PE showed similar results.

CONCLUSION

CAC is frequent in acute PE patients and associated with short-term mortality. Visual assessment of CAC may serve as an easy, readily available tool for early risk stratification in those patients.

KEY POINTS

• Coronary artery calcification assessed on computed tomography pulmonary angiography is frequent in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography is associated with 30-day overall and PE-related mortality in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography may serve as an additional, easy readily available tool for early risk stratification in those patients.

Acute pulmonary embolism multimodality imaging prior to endovascular therapy

The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.

Decreased size of the left anterior descending coronary artery is an independent predictor of deterioration in non-high-risk patients with acute pulmonary embolism

To evaluate the efficacy of measuring left coronary artery size to predict deterioration in non-high-risk acute pulmonary embolism (PE) patients. This retrospective study enrolled non-high-risk acute PE patients from January 2011 to December 2019. Patient deterioration was defined as the occurrence of adverse events within 30 days of hospital admission. Patients with adverse events were sex- and age-matched to patients without adverse events. Risk stratification was performed. Cross-sectional areas (CSAs) of the left main and left anterior descending (LAD) coronary artery inlets were measured. The main pulmonary artery (MPA) inlet and outlet and MPA LAD plane, which adjoined the LAD in the MPA, were reconstructed. CSAs, perimeters, and hydraulic diameters were measured to evaluate MPA size and deformation. Cardiac volume was also measured. Quantitative parameters were divided into tertiles. After adjustment by risk stratification, univariate and multivariate analyses were performed. Correlations between different parameters were analysed. Seventy-three patients with adverse events were matched to 73 patients without adverse events. The results of the univariate and multivariate analyses revealed that LAD inlet CSAs (middle and high) predicted adverse events (odds ratio: 0.28 and 0.07, 95% confidence interval: 0.10-0.77 and 0.02-0.22, p = 0.013 and < 0.0001). LAD inlet CSA was strongly and negatively correlated with MPA LAD hydraulic diameter and CSA (correlation coefficients: - 0.643 and - 0.604, p < 0.001). LAD inlet CSA measurement would facilitate adverse event prediction in non-high-risk acute PE patients on the basis of risk stratification. The dilated MPA may involve the decrease in LAD inlet CSA.

The use of computed tomography pulmonary angiography in the diagnosis of heart failure in the acute setting

BACKGROUND

Heart failure is a clinical diagnosis characterised by non-specific symptoms such as dyspnoea, fatigue and oedema. The aim of this pilot study was to investigate what role computed tomography pulmonary angiography could play in supporting a diagnosis of heart failure when a pulmonary embolism has been excluded.

METHODS

This was a prospective study using the National Integrated Medical Imaging System to assess the potential of computed tomography pulomary angiography (CTPA) as a diagnostic test for heart failure. Consecutive patients were collected from three hospitals of the University of Limerick Hospital Group. We reviewed 230 consecutive CTPA results for cardiac and lung features. Of these, we confirmed which had heart failure by comparison with brain natriuretic peptide (BNP) and echocardiogram criteria. Exclusion criteria included any patients with a diagnosis of pulmonary embolism.

RESULTS

Of these 230 patients, only 24 (10.4%) had both objective and clinical signs of heart failure. The most specific signs were shown to be left ventricular enlargement, left atrial enlargement and right ventricular enlargement, which approximated a specificity of 100% (CI 66.3-100.00%). CTPA was shown to match gold standard echocardiography closely in detecting abnormalities as per chi square; Right ventricular enlargement (value = 5.426 P = 0.02), left atrial enlargement (value = 4.9 P = 0.027) and left ventricular enlargement (value = 5.692 P = 0.017).

CONCLUSION

Findings on CTPA which included left ventricular enlargement, left atrial enlargement and right ventricular enlargement were shown to be specific for a diagnosis of heart failure. CTPA should be used by physicians awaiting echocardiography to help guide treatment in cases of suspected heart failure.

Systemic Thrombolysis Therapy is Associated With Improved Outcomes Among Patients With Acute Pulmonary Embolism and Respiratory Failure

BACKGROUND

Thrombolytic therapy is widely accepted for massive pulmonary embolism (PE) due to the high mortality risk associated with standard anticoagulation alone. Its role in submassive PE, however, has remained controversial. We aimed to evaluate whether the selective use of systemic thrombolytic therapy with intravenous tissue plasminogen activator (IV-tPA) improves the survival of patients with submassive PE at increased risk for clinical deterioration.

METHODS

A total of 184 consecutive patients diagnosed with acute PE by chest thoracic angiography (CTA) were included in a retrospective study. Pulmonary artery obstruction and right/left ventricular dysfunction were evaluated by CTA and echocardiography. Medical history and simplified PE Severity Index (sPESI) were assessed at diagnosis. Hemodynamic and respiratory status were recorded at diagnosis, admission to pulmonary unit and prior to thrombolytic therapy. Patient survival was assessed at 30 of 90 days from diagnosis by CTA.

RESULTS

All low risk patients (36%) per sPESI survived. Among the 117 remaining patients, 31% received IV-tPA. Respiratory failure was associated with decreased age-adjusted survival (P = 0.005). Among patients with respiratory failure selected for IV-tPA, age-adjusted survival was improved significantly compared to others (P = 0.043).

CONCLUSIONS

Thrombolytic therapy for hemodynamically stable PE patients with respiratory failure may improve survival.

TRIAL REGISTRATION

MMC-0216-14.

Right ventricular three-dimensional echocardiography: the current status and future perspectives

This review focused on right ventricular (RV) three-dimensional echocardiography (3DE) and discussed the following agenda. First, we summarized the clinical RV anatomy and function-related RV3DE use followed by the explanations about 3DSTE image acquisition, including pitfall. Next, we reviewed the reliability and feasibility of RV volume and RV ejection fraction measurements during the last decade. Besides, we described the techniques that might overcome the dropout images at RV anterior and out tract including the current limitations. Finally, speckle tracking echocardiography by RV3DE and novel RV shape assessment were reviewed. This review will help you get comprehensive information on the current status and future perspectives of RV3DE.

The Results of Thrombolytic Treatment in Patients With High-risk Pulmonary Embolism

Background: Mortality rates due to massive pulmonary embolism (PE) are much higher than estimated. Although thrombolytic therapy is controversial, it can be a life-saving procedure and can be safely used in patients with massive PE.

Study aim: We aimed to share the results of thrombolytic treatment in patients with massive PE.

Material and methods: We retrospectively evaluated 72 patients with PE admitted between January 2010 and April 2018 to the Department of Pulmonary Medicine, VM Medicalpark Samsun Hospital, Samsun, Turkey. The data of patients who received thrombolytic treatment were retrospectively analyzed.

Results: The female to male ratio was 24/48, with a mean age of 62.7 ± 12.6 (minimum 27, maximum 88) years. The diagnosis of massive PE was established with echocardiography in all patients and was confirmed via pulmonary CT angiography in 45 patients (62.5%) who presented an appropriate clinical status for this imaging technique. The most common symptoms were dyspnea (90.3%), chest pain (83.3%), and syncope (40.2%). The S1Q3T3 electrocardiography pattern was noted in 82% of patients, who rapidly recovered after thrombolytic therapy. Cardiopulmonary arrest was seen in 25 patients (37.2%), and thrombolytic treatment was administered during cardiopulmonary resuscitation in 18% (n = 13) of patients. The survival rate was 30.7% (n = 4) in patients with cardiopulmonary arrest who received thrombolytic treatment in the emergency room. The complications of rt-PA treatment included minor hemorrhages in 6.4% (n = 5), major hemorrhages in 2.7% (n = 2), and allergic reactions in 1.3% (n = 1) of patients. None of the patients had deceased as a complication of thrombolytic treatment. The overall mortality rate was 26.2% (n = 19), and 12.5% (n = 9) of the patients have died in first 24 hours after thrombolysis.

Conclusions: We concluded that the risk factors, ECG, and echocardiography are key indicators for the suspicion of massive PE in patients with hemodynamic shock. Based on our experience, early thrombolytic therapy is a life-saving intervention in patients with diagnosed and/or suspected massive PE.

Ambulatory management of pulmonary embolism

The diagnosis of pulmonary embolism can be very difficult and elusive. It depends greatly on the use of diagnostic tests, which are in turn interpreted according to a pre-test clinical probability. These include non-specific tests such as the chest X-ray and electrocardiograph, which help exclude other conditions such as pneumonia or myocardial infarction. On the other hand, more specific tests such as computed tomography or ventilation/perfusion scanning are used to confirm or exclude the diagnosis of pulmonary embolism. The condition is potentially fatal, and in the past patients with suspected pulmonary embolism constituted a significant number of hospital admissions. Despite this, the majority were found not to have pulmonary embolism. More recently, studies have suggested that most patients with suspected pulmonary embolism who are haemodynamically stable can be safely managed on an ambulatory pathway. Therefore, there is a paradigm shift towards investigating and treating pulmonary embolism in the outpatient setting. This article discusses the ambulatory pathway of the diagnosis and treatment of pulmonary embolism.

A decision tree built with parameters obtained by computed tomographic pulmonary angiography is useful for predicting adverse outcomes in non-high-risk acute pulmonary embolism patients

Background

Acute pulmonary embolism (APE) is one of the leading causes of death in cardiovascular disease. The 30-day mortality can still be 1.7–15% in non-high-risk APE patients. Some non-high-risk patients can progress into the high-risk group and even die, which is referred to as an adverse outcome. Promoting the diagnosis and predictive ability of adverse short-term prognosis was still a problem that needed to be solved. Computed tomography pulmonary angiography (CTPA) may be a way to promote the predictive ability. Our aim to develop predictive tools based on parameters obtained by computed tomographic pulmonary angiography (CTPA) in the form of a decision tree for use in non-high-risk acute pulmonary embolism (APE) patients.

Methods

Adverse outcome was defined within 30 days after admission to the hospital. A decision tree was built to predict adverse outcomes based on discriminating factors screened from cardiac volume and clot characteristics from recursive partitioning analysis and compared with simplified pulmonary embolism severity index (sPESI), Bova scores and risk stratification. The area under the receiver operating characteristic curve (ROC-AUC) was used to confirm the predictive ability.

Results

A total of 38 patients with and 303 patients without adverse outcomes were enrolled. Right ventricular/left ventricular (RV/LV) volume ratio, central pulmonary artery (CPA) embolism and right atria/left atria (RA/LA) volume ratio were used as splits in the decision tree to predict adverse outcomes in all patients. The ROC-AUC was 0.858. In CPA embolism patients, a recursive partitioning analysis was performed with cardiac volume and novel clot burden, but only the obstructing area (OA) ratio was included as a discriminating factor to build a second decision tree. The ROC-AUC for the second decision tree was 0.810. The decision trees were superior to those of sPESI, Bova scores and risk stratification, and there were no significant differences between the two decision trees.

Conclusions

A decision tree built by CTPA parameters can predict adverse outcomes in non-high-risk APE patients.

Should Perfusion Scintigraphy Be Performed to Follow Patients with Acute Pulmonary Embolism? If So, When?

This investigation evaluated the changes of pulmonary perfusion at 4 different points of follow-up within 1 y in patients with pulmonary embolism (PE) and the factors predictive of complete or incomplete recovery of pulmonary perfusion. Methods: Patients with symptomatic PE underwent perfusion lung scintigraphy and blood gas analysis within 48 h from clinical presentation, after 1 wk, and after 1, 6, and 12 mo; echocardiography was performed at baseline and after 6 and 12 mo. All perfusion lung scintigraphy scans were examined by 2 expert nuclear medicine physicians with a scoring method that attributed a score of 0, 0.5, or 1 for extension (maximum score, 18) to the presence of perfusion defects (PD), both at baseline and on each follow-up scan. Results: Among 183 patients who completed 1 y of follow-up, the median baseline PD score was 8.2; it decreased significantly at each follow-up time point until 6 mo (P < 0.001). Median baseline alveolar-arterial difference in oxygen partial pressure (PA-aO₂) was 50.9 and decreased significantly up to 1 mo (P < 0.001); median pulmonary artery systolic pressure (PAsP) was 45.9 mm Hg and decreased significantly until 12 mo (P < 0.001). A correlation was found between PD and both PA-aO₂ (P < 0.05) and PAsP (P < 0.05). We found a correlation between PD ≠ 0 and PAsP ≥ 40 mm Hg at 12 mo (P < 0.05); in 6 (3.3%) of these patients such a correlation was still present after 24 mo, suggesting they could develop chronic thromboembolic pulmonary hypertension. Low baseline PD (odds ratio, 0.80; P < 0.0001) and high 1-wk percent recovery (odds ratio, 1.04; P < 0.0001) were predictive factors of complete 6-mo recovery. Conclusion: Perfusion scintigraphy may be useful to follow patients with PE. The follow-up should consist of 3 steps: the baseline examination, which reflects the severity of PE; the scan at 1 wk, which indicates the early amount of reperfusion; and the scan at 6 mo, which demonstrates the maximum attainable recovery. Patients with incomplete recovery and persistence of pulmonary hypertension on the 24-mo control should be further studied for possible development of chronic thromboembolic pulmonary hypertension.

Saddle Pulmonary Embolus Caught in Transit across a Patent Foramen Ovale

Impending paradoxical embolism (IPE) also described in the literature as thrombus straddling a patent foramen ovale (PFO) or paradoxical embolus in transit is a rare condition when thrombus (originating mostly in deep veins of lower extremities) embolized to the heart gets caught in PFO or in atrial septal defect without systemic embolization. We present a case of a 39-year-old female on oral contraceptive pills who presented to the emergency department with chief complaint of dyspnea and chest pain. She was found to have saddle pulmonary embolus (PE) extending through PFO to left atrium and into the left ventricle. Patient underwent emergent open pulmonary embolectomy, removal of right and left atrial thrombi, and closure of patent foramen ovale. She tolerated the surgery well and was discharged home on chronic anticoagulation therapy.

Incidental Cardiac Findings in Non-Electrocardiogram-gated Thoracic Computed Tomography of Intensive Care Unit Patients: Assessment of Prevalence and Underreporting

PURPOSE

Cardiac findings frequently remain unreported on non-electrocardiogram (ECG)-gated computed tomography (CT). Although the clinical relevance of such findings may be limited in a general patient population, they may have significant impact in intensive care patients. Thus, the purpose of this study was to evaluate the prevalence, underreporting, and clinical relevance of incidental cardiac findings in intensive care unit (ICU) patients.

MATERIALS AND METHODS

Non-ECG-gated chest CT examinations of ICU patients were retrospectively analyzed for incidental cardiac findings. The findings were classified into 3 categories (A to C): category A findings, which carry potential for risk to life; category B findings, which have a potential for significant morbidity; category C findings, which have a possible effect on prognosis.

RESULTS

A total of 500 patients who underwent non-ECG-gated thoracic CT examinations were included. Of the 500 patients, 403 presented with 1443 cardiac findings. Of all cardiac findings, 37% were described in the initial written report. Sixty category A findings were detected, of which 48% were not mentioned in the report. Six hundred forty category B findings were detected, of which 77% were not described in the report. The remaining 743 findings were classified as category C, 55% of which were not reported in the report.

CONCLUSIONS

The prevalence as well as the rate of underreporting of incidental cardiac findings in non-ECG-gated chest CT of ICU patients is very high. The results of this study underscore the importance of dedicated training for assessment of cardiac structures and conditions, which may be detected on non-ECG-gated chest CT.