1
|
Aissa A, Mallat N, Aissa S, Alouini R. [Contribution of pulmonary CT angiography in assessing the severity of acute pulmonary embolism]. Ann Cardiol Angeiol (Paris) 2019; 68:71-79. [PMID: 30172353 DOI: 10.1016/j.ancard.2018.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
Chest CT angiography has taken a major role in the management of patients with suspected pulmonary embolism. Meanwhile, it became necessary to determine the severity criteria at the time of diagnosis in order to properly assess the risk/benefit of treatment to consider. In recent years, pulmonary CT angiography has emerged as a useful tool for assessing the severity of acute lung embolism, based on morphological criteria. The two main approaches that were studied were the quantification of obstruction of pulmonary arterial bed and recognition of signs of right heart failure. The aim of our work is to define the morphological parameters in cardiovascular pulmonary CT angiography and to determine their value in the current clinical prognostic stratification of acute pulmonary embolism of, especially their correlation with the risk of developing signs of clinical severity at diagnosis and at 3 months of the occurrence of pulmonary embolism.
Collapse
Affiliation(s)
- A Aissa
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie.
| | - N Mallat
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie
| | - S Aissa
- Service de pneumologie clinique, CHU Farhat Hached de Sousse, Sousse Tunisie
| | - R Alouini
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie
| |
Collapse
|
2
|
Wang J, Guan W, Chen D, Han Y, Xu Z, Qiang J, Chen W, Li N, Gao W. The value of CTPA for diagnosing acute pulmonary thromboembolism and the ensuing right ventricular dysfunction. Cell Biochem Biophys 2015; 69:517-22. [PMID: 24526352 DOI: 10.1007/s12013-014-9826-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The value of computed tomography pulmonary angiography (CTPA) for the diagnosis of right ventricular dysfunction (RVD) subsequent to acute pulmonary embolism (PE). The ultrasonic cardiography (UCG) was used to assess RVD, one of the diagnostic criteria of PE caused hemodynamic collapse. Seventy six patients with confirmed PE were divided into massive (52 cases) and non-massive PE group (24 cases). The diagnostic criteria assessed for the imminent RVD were: (1) the ratio of axial diameters of the right and left ventricular chambers (RVd/LVd) exceeding 1, or (2) the right ventricular end-diastolic diameter measuring >30 mm. The CTPA diagnosed RVD was positive in 36 and negative in 40 cases. The RVD assessed by UCG was positive in 31 and negative in 45 cases. In comparison to UCG, the CTPA results UCG exhibited 96.77 % sensitivity 96.77 % and 86.67 specificity. The evaluated values both of these techniques were found in good agreement by the kappa value (κ) of 0.81, P < 0.001. In 52 cases of massive PE, CTPA determined RVD was positive in 34, and negative in 18 cases. In comparison, UCG diagnosed RVD was positive in 31 and negative in 21 cases. The sensitivity and specificity of CTPA results compared to those of UCG were 91.18 and 85.71 %, respectively. The estimates obtained were in good agreement as indicated by 0.88 κ value and P < 0.001. Twenty four cases of non-massive PE were RVD negative when assessed by CTPA, UCG however showed two cases positive in this group. Compared to UCG, the specificity of CTPA in evaluating RVD was 100 %. In the massive PE group, the average estimate of RVd/LVd ratio was significantly higher than 1 as analyzed by the non-parametric Mann-Whitney test (P < 0.001). The CTPA and UCG results showed a good correlation in massive PE cases. However, in non-massive PE group, results from two techniques were not correlated. The CTPA can accurately and reliably diagnose the PE and ensuing by estimating changes in the anatomical parameters of right ventricle. Hence, it can allow prompt diagnosis and an appropriate treatment leading to an improved prognosis.
Collapse
Affiliation(s)
- Jian Wang
- Department of Radiology, First Affiliated Hospital of Henan University of Technology, Luoyang, 471003, China
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
|
4
|
Liu M, Ma Z, Guo X, Chen X, Yang Y, Wang C. Cardiovascular parameters of computed tomographic pulmonary angiography to assess pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol 2013; 164:295-300. [DOI: 10.1016/j.ijcard.2011.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 06/18/2011] [Accepted: 07/03/2011] [Indexed: 10/17/2022]
|
5
|
Clot burden score in the evaluation of right ventricular dysfunction in acute pulmonary embolism: Quantifying the cause and clarifying the consequences. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
6
|
Rodrigues B, Correia H, Figueiredo A, Delgado A, Moreira D, Ferreira Dos Santos L, Correia E, Pipa J, Beirão I, Santos O. [Clot burden score in the evaluation of right ventricular dysfunction in acute pulmonary embolism: quantifying the cause and clarifying the consequences]. Rev Port Cardiol 2012; 31:687-95. [PMID: 23062526 DOI: 10.1016/j.repc.2012.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 02/13/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pulmonary angiography by computed tomography (CT) is the method of choice for the detection of acute pulmonary embolism (PE). Studies have shown that the severity of PE can be estimated by clot burden scores. OBJECTIVE To evaluate the correlation between an angiographic clot burden score (Qanadli score - QS) and parameters of right ventricular dysfunction (RVD) in patients admitted for PE. METHODS We performed a retrospective study of 107 patients (60% female) admitted to an intensive care unit for PE (intermediate/high risk) between January 1, 2007 and September 30, 2011. Images from 16-slice multidetector CT angiography were reviewed in 102 patients and the QS calculated. Based on a cut-off of 18 points established by ROC curve analysis, two groups were formed (A<18 points vs. B ≥18 points) and the clinical, laboratory, ECG, echocardiographic and CT angiography parameters were compared. The statistical analysis was performed using SPSS. RESULTS The overall mean age was 61.4 years. With regard to symptoms at admission, there was a greater prevalence in group B of fatigue, chest pain and syncope (p=0.017), with higher Geneva and Wells scores and shock index. In terms of ECG parameters, heart rate and percentage of right bundle branch block, T-wave inversion (V(1)-V(3)) and S(1)Q(3)T(3) pattern (p=0.034) were higher in group B, as was the ECG score (p=0.009). Laboratory tests revealed that group B had higher troponin and d-dimers, with lower creatinine clearance by the MDRD formula (p=0.020) and PO(2)/FiO(2) ratio. Echocardiography showed higher pulmonary artery systolic pressure in group B, and CT angiography revealed larger right ventricular (RV) diameters and higher RV/LV ratio (p=0.002), and greater superior vena cava, azygos vein and coronary sinus diameters in this group. Pulmonary artery (PA) diameter and the PA/aorta ratio were similar. Interventricular septal bowing and reflux of contrast into the inferior vena cava (p=0.001) were greater in group B, and QS>18 was an independent predictor of RVD (RV/LV ratio>1) (OR: 10.85; p<0.001) (area under the curve on ROC analysis: 0.79; p<0.001). The percentage of patients receiving fibrinolytic treatment was higher in group B (p=0.045), and in-hospital mortality was similar in both groups (overall 4.9%). CONCLUSIONS QS >18 points proved to be an independent predictor of RVD in PE, and correlated linearly with variables associated with higher morbidity and mortality.
Collapse
Affiliation(s)
- Bruno Rodrigues
- Serviço de Cardiologia/Radiologia, Centro Hospitalar Tondela-Viseu, Hospital São Teotónio, Viseu, Portugal.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Ley S, Grünig E, Kiely DG, van Beek E, Wild J. Computed tomography and magnetic resonance imaging of pulmonary hypertension: Pulmonary vessels and right ventricle. J Magn Reson Imaging 2011; 32:1313-24. [PMID: 21105137 DOI: 10.1002/jmri.22373] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is very heterogeneous and the classification identifies five major groups including many associated disease processes. The treatment of PH depends on the underlying cause and accurate classification is paramount. A comprehensive assessment to identify the cause and severity of PH is therefore needed. Furthermore, follow-up assessments are required to monitor changes in disease status and response to therapy. Traditionally, the diagnostic imaging work-up of PH comprised mainly echocardiography, invasive right heart catheterization, and ventilation/perfusion scintigraphy. Due to technical advances, multidetector row computed tomography (CT) and magnetic resonance imaging (MRI) have become important and complementary investigations in the evaluation of patients with suspected PH. Both modalities are reviewed and recommendations for clinical use are given.
Collapse
Affiliation(s)
- Sebastian Ley
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
| | | | | | | | | |
Collapse
|
8
|
Non-severe pulmonary embolism: prognostic CT findings. Eur J Radiol 2010; 79:452-8. [PMID: 20403673 DOI: 10.1016/j.ejrad.2010.03.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 03/15/2010] [Indexed: 11/22/2022]
Abstract
The goal of this study was to retrospectively evaluate CT cardiovascular parameters and pulmonary artery clot load score as predictors of 3-month mortality in patients with clinically non-severe pulmonary embolism (PE). We included 226 CT positive for PE in hemodynamically stable patients (112 women; mean age 67.1 years ± 16.9). CT were independently reviewed by two observers. Results were compared with occurrence of death within 3 months using Cox regression. Twenty-four (10.6%) patients died, for whom 9 were considered to be due to PE. Interobserver agreement was moderate for the shape of interventricular septum (κ = 0.41), and for the ratio between the diameters of right and left ventricle (RV/LV) (κ = 0.76). Observers found no association between interventricular septum shape and death. A RV/LV diameter ratio >1 was predictive of death (OR, 3.83; p < 0.01) only when we also took into account the value of the embolic burden (< 40%). In a multivariate model, CT cardiovascular parameters were not associated with death. Concomitant lower limb DVT and comorbid conditions were important predictors of death. In clinically non-severe PE, a RV/LV diameter ratio >1 is predictive of death when the embolic burden is low (< 40%).
Collapse
|
9
|
Jeebun V, Doe SJ, Singh L, Worthy SA, Forrest IA. Are clinical parameters and biomarkers predictive of severity of acute pulmonary emboli on CTPA? QJM 2010; 103:91-7. [PMID: 20040533 DOI: 10.1093/qjmed/hcp162] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies have shown that findings of computed tomography pulmonary angiography (CTPA) relate to outcome in pulmonary embolus (PE). These include clot burden as quantified using an obstruction index and markers of pressure overload such as right ventricle to left ventricle size ratio (RV/LV ratio). Little data exists correlating these findings with clinical presentation and biomarkers. AIM To explore the link between clinical presentation and biomarkers with CTPA findings. METHODS Retrospective case note analysis of consecutive cases presenting to a large teaching hospital. An independent radiologist reviewed CTPAs and clot burden quantified using an obstruction index. RESULTS One hundred and seventy cases were identified and notes retrieved in 137 cases. (i) CLINICAL PRESENTATION correlation was seen between clot burden and systolic blood pressure (BP) (r = -0.299, P = 0.0006) and heart rate (r = 0.240, P = 0.0056). Median obstruction index was significantly higher in those with a presenting BP <90 mmHg [41.25% (95% CI 30-50) vs. 15% (95% CI 12.5-25), (P = 0.0004)]. Clot burden was significantly higher in patients with temperature of >37.5 degrees C [30% (95% CI 25.0-42.5) vs. 15% (95% CI 12.5-28.3), P = 0.02)] and (ii)Biomarkers: significant correlation between clot burden and D-dimer was seen (r = 0.36, P = 0.0001). Location of thrombus was associated with significant differences in D-dimer level. A subgroup of patients had cardiac biomarkers measured (n = 24). There was a statistically significant correlation between troponin I and clot burden (r = 0.412, P = 0.048) and RV/LV ratio (r = 0.699, P = 0.0013). DISCUSSION These findings suggest that clinical parameters and biomarkers have a role in predicting the radiological severity of PE. These data support the need for further studies of risk stratification in patients presenting with acute PE.
Collapse
Affiliation(s)
- V Jeebun
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK.
| | | | | | | | | |
Collapse
|
10
|
Wang J, Zhu L, Liu M, Guo X, Wang C, Guo Y, Yang Y, Zhai Z, Ma H, Guo Y. The value of CT pulmonary angiography to the diagnosis of right ventricular dysfunction due to acute pulmonary embolism: compared with ultrasonographic cardiography. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1007-4376(08)60070-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
11
|
Coppenrath E, Herzog P, Attenberger U, Reiser M. Chronische Lungenembolie – Radiologische Bildmorphologie und Differenzialdiagnose. Radiologe 2007; 47:691-7. [PMID: 17624509 DOI: 10.1007/s00117-007-1531-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In chronic pulmonary embolism branches of the pulmonary arterial tree remain partially or totally occluded. This may lead to pulmonary hypertension with the development of right ventricular hypertrophy as well as structural changes of pulmonary arteries. Imaging of chronic pulmonary embolism should prove vessel occlusions (pulmonary angiography, MSCT, MRI) and reduction of regional lung perfusion (lung scanning, MSCT, MRI). According to current guidelines ventilation-perfusion lung scanning and pulmonary angiography are still recommended as the methods of choice. MSCT and MRI provide technical alternatives which are helpful in differential diagnosis versus other types of pulmonary hypertension. In spite of medical and surgical measures (in rare cases pulmonary thromboendarterectomy) the prognosis of chronic pulmonary embolism remains unfavourable.
Collapse
Affiliation(s)
- E Coppenrath
- Institut für Klinische Radiologie, Klinikum Innenstadt der Ludwig-Maximilians-Universität München, Ziemssenstrasse 1, 80336 Munich, Germany.
| | | | | | | |
Collapse
|
12
|
Abstract
Multidetector-row computed tomographic (CT) angiography of pulmonary arteries is the first-line imaging technique in patients suspected of having pulmonary embolism (PE). Patient risk stratification is important because optimal management, monitoring, and therapeutic strategies depend on the patient's prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe PE. Acute right-sided heart failure can be assessed on CT pulmonary angiography by measuring the dimensions of the right-sided heart cavities or systemic veins. The magnitude of PE can be calculated on CT pulmonary angiography by applying dedicated CT scores or angiographic scores adapted. This article reviews and discusses the various CT-based methods for risk stratification of patients with acute PE.
Collapse
Affiliation(s)
- C Engelke
- Institut für Röntgendiagnostik, Klinikum der Bayerischen Julius-Maximilians-Universität Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
| | | |
Collapse
|
13
|
Ghaye B, Ghuysen A, Willems V, Lambermont B, Gerard P, D'Orio V, Gevenois PA, Dondelinger RF. Severe pulmonary embolism:pulmonary artery clot load scores and cardiovascular parameters as predictors of mortality. Radiology 2006; 239:884-91. [PMID: 16603659 DOI: 10.1148/radiol.2392050075] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To retrospectively evaluate pulmonary artery (PA) clot load scores and computed tomographic (CT) cardiovascular parameters as predictors of mortality in patients with severe pulmonary embolism (PE). MATERIALS AND METHODS Institutional review board approval was obtained with waiver of informed consent. A total of 82 consecutive patients (42 women, 40 men; mean age+/-standard deviation, 61 years+/-15) were admitted to the intensive care unit for PE-related conditions and were evaluated by using CT pulmonary angiography. Two independent readers who were blinded to clinical outcome quantified PA clot load by using four scoring systems. Cardiovascular measurements included right ventricular (RV) and left ventricular (LV) short-axis measurements; RV short axis to LV short axis (RV/LV) ratios; main PA, ascending aorta, azygos vein, and superior vena cava diameters; and main PA diameter to aorta diameter ratios. Reflux of contrast medium into the inferior vena cava, leftward bowing of the interventricular septum, pleural or pericardial effusion, pulmonary consolidation, infarct, platelike atelectasis, and mosaic ground-glass opacity were also recorded. Results were correlated with patient outcome during hospital stay by using the Wilcoxon rank sum and chi2 tests. RESULTS Twelve patients died within 1-14 days. RV and LV short axis; RV/LV ratio; azygos vein, superior vena cava, and aorta diameters; and contrast medium reflux into the inferior vena cava were significantly different between survivors and nonsurvivors (P<.05). No significant relationship was found between PA clot load and mortality rate. RV/LV ratio and azygos vein diameter allowed correct prediction of survival in 89% of patients (P<.001). CONCLUSION RV/LV ratio and azygos vein diameter are predictors of mortality in patients with severe PE.
Collapse
Affiliation(s)
- Benoit Ghaye
- Department of Medical Imaging and Medicine, University Hospital of Liege, B35 Sart Tilman, B-4000 Liege, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Ghaye B, Ghuysen A, Bruyere PJ, D'Orio V, Dondelinger RF. Can CT pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? What the radiologist needs to know. Radiographics 2006; 26:23-39; discussion 39-40. [PMID: 16418240 DOI: 10.1148/rg.261055062] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Computed tomographic (CT) pulmonary angiography has been established as a first-line diagnostic technique in patients suspected of having pulmonary embolism. Risk stratification is important in patients with pulmonary embolism because optimal management, monitoring, and therapeutic strategies depend on the prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe pulmonary embolism. Acute right-sided heart failure can be assessed at CT pulmonary angiography by measuring the dimensions of right-sided heart cavities or upstream venous structures, such as the superior vena cava or azygos vein. The magnitude of pulmonary embolism can be calculated at CT pulmonary angiography by applying angiographic scores adapted for CT (Miller and Walsh scores) or dedicated CT scores (Qanadli and Mastora scores). The advent of CT pulmonary angiography performed with electrocardiographic gating permits new advances in assessment of acute right-sided heart failure, such as measurement of the ventricular ejection fraction. Although such findings may be useful for assessment of treatment effectiveness, their effect on prognosis in patients with severe pulmonary embolism is debated in the literature.
Collapse
Affiliation(s)
- Benoît Ghaye
- Department of Medical Imaging, University Hospital of Liege, Sart Tilman B35, B-4000 Liege, Belgium.
| | | | | | | | | |
Collapse
|
15
|
Wildberger JE, Schoepf UJ, Mahnken AH, Herzog P, Ditt H, Niethammer MU, Schaller S, Klotz E, Günther RW. Approaches to CT perfusion imaging in pulmonary embolism. Semin Roentgenol 2005; 40:64-73. [PMID: 15732562 DOI: 10.1053/j.ro.2004.09.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Computed tomography (CT) has become an increasingly accepted technique and is the method of choice for direct visualization of pulmonary emboli (PE). The quantitative assessment of tissue perfusion may yield more important information for patient management than the direct visualization of emboli by CT alone. Several attempts have been made to measure pulmonary blood flow by administration of intravenous contrast material. In this article, various experimental CT approaches for visualization and quantification of pulmonary perfusion are discussed. Ideally, CT will be able to provide both structural and functional information. Simple measurement of lung density before and after intravenous contrast delivery has been performed with single-slice CT technology using region-of-interest methodology. For electron-beam CT, a repeated data acquisition on a 7.6-cm lung volume has proven to be technically feasible. Using such dynamic scanning, reduced blood flow was observed in occluded lung segments. Color-encoded parenchymal density distribution in the axial, coronal, and sagittal planes was derived from thin collimation data sets using four-row multi-slice spiral CT (MSCT). Initial animal data from 16-slice MSCT offer a real CT-subtraction technique of the entire chest for the first time.
Collapse
|
16
|
van der Meer RW, Pattynama PMT, van Strijen MJL, van den Berg-Huijsmans AA, Hartmann IJC, Putter H, de Roos A, Huisman MV. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005; 235:798-803. [PMID: 15845793 DOI: 10.1148/radiol.2353040593] [Citation(s) in RCA: 343] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively quantify right ventricular dysfunction (RVD) and the pulmonary artery obstruction index at helical computed tomography (CT) on the basis of various criteria proposed in the literature and to assess the predictive value of these CT parameters for mortality within 3 months after the initial diagnosis of pulmonary embolism (PE). MATERIALS AND METHODS Institutional review board approval was obtained, and informed consent was not required for retrospective study. In 120 consecutive patients (55 men, 65 women; mean age +/- standard deviation, 59 years +/- 18) with proved PE, two readers assessed the extent of RVD by quantifying the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) and the pulmonary artery to ascending aorta diameters, the shape of the interventricular septum, and the extent of obstruction to the pulmonary artery circulation on helical CT images, which were blinded for clinical outcome in consensus reading. Regression analysis was used to correlate these parameters with patient outcome. RESULTS CT signs of RVD (RV/LV ratio, >1.0) were seen in 69 patients (57.5%). During follow-up, seven patients died of PE. Both the RV/LV ratio and the obstruction index were shown to be significant risk factors for mortality within 3 months (P = .04 and .01, respectively). No such relationship was found for the ratio of the pulmonary artery to ascending aorta diameters (P = .66) or for the shape of the interventricular septum (P = .20). The positive predictive value for PE-related mortality with an RV/LV ratio greater than 1.0 was 10.1% (95% confidence interval [CI]: 2.9%, 17.4%). The negative predictive value for an uneventful outcome with an RV/LV ratio of 1.0 or less was 100% (95% CI: 94.3%, 100%). There was a 11.2-fold increased risk of dying of PE for patients with an obstruction index of 40% or higher (95% CI: 1.3, 93.6). CONCLUSION Markers of RVD and pulmonary vascular obstruction, assessed with helical CT at baseline, help predict mortality during follow-up.
Collapse
Affiliation(s)
- Rutger W van der Meer
- Department of General Internal Medicine, Leiden University Medical Center, Albinusdreef 2, Rm C1 R 43, 2300 RC Leiden, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Wildberger JE, Klotz E, Ditt H, Spüntrup E, Mahnken AH, Günther RW. Multislice computed tomography perfusion imaging for visualization of acute pulmonary embolism: animal experience. Eur Radiol 2005; 15:1378-86. [PMID: 15776240 DOI: 10.1007/s00330-005-2718-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 01/14/2005] [Accepted: 01/21/2005] [Indexed: 10/25/2022]
Abstract
The purpose of our animal study was to evaluate a new computed tomography (CT) subtraction technique for visualization of perfusion defects within the lung parenchyma in subsegmental pulmonary embolism (PE). Seven healthy pigs were entered into a prospective trial. Acute PE was artificially induced by fresh clot material prior to the CT scans. Within a single breath-hold, whole thorax CT scans were performed with a 16-slice multidetector-row CT scanner (SOMATOM Sensation 16; Siemens, Forchheim, Germany) before and after intravenous application of 80 ml of contrast medium with a flow rate of 4 ml/s, followed by a saline chaser. The scan parameters were 120 kV and 100 mAs(eff), using a thin collimation of 16x0.75 mm and a table speed/rotation of 15-18 mm (pitch, 1.25-1.5; rotation time, 0.5 s). Axial source images were reconstructed with an effective slice thickness of 1 mm (overlap, 30%). A new automatic subtraction technique was used. After 3D segmentation of the lungs in the plain and contrast-enhanced series, threshold-based extraction of major airways and vascular structures in the contrast images was performed. This segmentation was repeated in the plain CT images segmenting the same number of vessels and airways as in the contrast images. Both scans were registered onto each other using nonrigid registration. After registration both image sets were filtered in a nonlinear fashion excluding segmented airways and vessels. After subtracting the plain CT data from the contrast data the resulting enhancement images were color-encoded and overlaid onto the contrast-enhanced CT angiography (CTA) images. This color-encoded combined display of parenchymal enhancement of the lungs was evaluated interactively on a workstation (Leonardo, Siemens) in axial, coronal and sagittal plane orientations. Axial contrast-enhanced CTA images were rated first, followed by an analysis of the combination images. Finally, CTA images were reread focusing on areas with perfusion deficits indicating PE on the color-coded enhancement display. Subtraction was feasible for all seven studies. In one animal, opacification of the pulmonary arteries was suboptimal owing to heart insufficiency. In the remaining six pigs, a total of 37 perfusion defects were clearly assessable downstream of occluded subsegmental arteries, showing lower or missing enhancement compared with normally perfused lung parenchyma. Indeterminate findings from CTA showed typical PE perfusion defects in four out of six cases on CT subtraction. Additionally, 22 peripheral triangular-shaped enhancement defects were delineated. Nine of these findings were reclassified as definitely being caused by PE on second reading of the CTA data sets. Our initial results have shown that this new subtraction technique for perfusion imaging of PE is feasible, using routine contrast delivery. Dedicated examination protocols are mandatory for adequate opacification of the pulmonary arteries and for optimization of data sets for subsequent subtraction. Perfusion imaging allows a comprehensive assessment of morphology and function, providing more accurate information on acute PE.
Collapse
|
18
|
Wildberger JE, Mahnken AH, Das M, Küttner A, Lell M, Günther RW. CT imaging in acute pulmonary embolism: diagnostic strategies. Eur Radiol 2005; 15:919-29. [PMID: 15662491 DOI: 10.1007/s00330-005-2643-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 12/21/2004] [Accepted: 12/27/2004] [Indexed: 10/25/2022]
Abstract
Computed tomography pulmonary angiography (CTA) has increasingly become accepted as a widely available, safe, cost-effective, and accurate method for a quick and comprehensive diagnosis of acute pulmonary embolism (PE). Pulmonary catheter angiography is still considered the gold standard and final imaging method in many diagnostic algorithms. However, spiral CTA has become established as the first imaging test in clinical routine due to its high negative predictive value for clinically relevant PE. Despite the direct visualization of clot material, depiction of cardiac and pulmonary function in combination with the quantification of pulmonary obstruction helps to grade the severity of PE for further risk stratification and to monitor the effect of thrombolytic therapy. Because PE and deep venous thrombosis are two different aspects of the same disease, additional indirect CT venography may be a valuable addition to the initial diagnostic algorithm-if this was positive for PE-and demonstration of the extent and localization of deep venous thrombosis has an impact on clinical management. Additional and alternate diagnoses add to the usefulness of this method. Using advanced multislice spiral CT technology, some practitioners have advocated CTA as the sole imaging tool for routine clinical assessment in suspected acute PE. This will simplify standards of practice in the near future.
Collapse
Affiliation(s)
- Joachim E Wildberger
- Department of Diagnostic Radiology, University Hospital, University of Technology (RWTH), Aachen, Germany.
| | | | | | | | | | | |
Collapse
|
19
|
Ferretti GR, Collomb D, Ravey JN, Vanzetto G, Coulomb M, Bricault I. Severity assessment of acute pulmonary embolism: Role of CT angiography. Semin Roentgenol 2005; 40:25-32. [PMID: 15732558 DOI: 10.1053/j.ro.2004.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Helical CT has gained wide acceptance in the noninvasive diagnosis of acute pulmonary embolism (APE) and has therefore largely replaced conventional pulmonary angiography as well as ventilation perfusion scan in the work-up of patients suspected of nonsevere pulmonary embolism (PE). Massive PE is life-threatening; its occurrence may require aggressive treatment such as thrombolysis or embolectomy. Identification of patients suffering from major thromboembolic events based solely on clinical grounds may, however, be difficult. Acute right heart failure is the principal cause of circulatory collapse and death for patients with massive PE, and rapid and specific diagnosis and therapy are required in such patients. Bedside echocardiography, a commonly performed first-line examination, demonstrates signs of cor pulmonale, if present, and can identify large central thrombi. However, echocardiography has limitations. In this review, our goal is to discuss the potential role of CT in assessing patients with severe APE. CT evaluation is based on the direct quantification of pulmonary arterial bed obstruction using various scores and the evaluation of morphological heart changes indicating acute cor pulmonale.
Collapse
|
20
|
Kreitner KFJ, Ley S, Kauczor HU, Mayer E, Kramm T, Pitton MB, Krummenauer F, Thelen M. Chronic Thromboembolic Pulmonary Hypertension: Pre- and Postoperative Assessment with Breath-hold MR Imaging Techniques. Radiology 2004; 232:535-43. [PMID: 15215554 DOI: 10.1148/radiol.2322030945] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the potential of breath-hold magnetic resonance (MR) imaging techniques in morphologic and functional assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after surgery. MATERIALS AND METHODS Thirty-four patients with CTEPH were examined before and after pulmonary thromboendarterectomy (PTE). For morphologic assessment, contrast material-enhanced MR angiography was used; for assessment of hemodynamics, velocity-encoded gradient-echo sequences and cine gradient-echo sequences along the short axis of the heart were performed. Contrast-enhanced MR angiography was compared with selective digital subtraction angiography (DSA) for depiction of central thromboembolic material and visualization of the pulmonary arterial tree. Functional analysis included calculation of left and right ventricular ejection fractions and peak velocities, net forward volumes per heartbeat, and blood volume per minute in the left and right pulmonary arteries and ascending aorta. Flow measurements were compared with invasively measured mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR) measurements. Nonparametric Wilcoxon and sign tests were used for statistical analysis. RESULTS MR angiography revealed typical findings of CTEPH (intraluminal webs and bands, vessel cutoffs, and organized central thromboemboli) in all patients. It depicted pulmonary vessels up to the segmental level in all cases. For subsegmental arteries, DSA revealed significantly more patent vessel segments than did MR angiography (733 versus 681 segments, P <.001). MR angiography revealed technical success of surgery in 33 of 34 patients. Patients had reduced right ventricular ejection fractions and pulmonary peak velocities that significantly increased after PTE (P <.001 for both). Right ventricular ejection fraction had good correlation with PVR (r = 0.6) and MPAP (r = 0.7). The postoperative decrease in MPAP correlated well with the increase in right ventricular ejection fraction (r = 0.8). Postoperatively, there was complete reduction of a preoperatively existing bronchosystemic shunt volume in 33 of 34 patients. CONCLUSION Breath-hold MR imaging techniques enable morphologic and semiquantitative functional assessment of patients with CTEPH.
Collapse
|
21
|
Schoepf UJ, Wildberger JE, Niethammer M, Herzog P, Schaller S. CT Perfusion Imaging of the Lung in Pulmonary Embolism. FUNCTIONAL IMAGING OF THE CHEST 2004. [DOI: 10.1007/978-3-642-18621-9_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
22
|
Collomb D, Paramelle PJ, Calaque O, Bosson JL, Vanzetto G, Barnoud D, Pison C, Coulomb M, Ferretti G. Severity assessment of acute pulmonary embolism: evaluation using helical CT. Eur Radiol 2003; 13:1508-14. [PMID: 12835961 DOI: 10.1007/s00330-002-1804-5] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2002] [Revised: 11/19/2002] [Accepted: 12/09/2002] [Indexed: 12/22/2022]
Abstract
The objective was to evaluate the helical CT (HCT) criteria that could indicate severe pulmonary embolism (PE). In a retrospective study, 81 patients (mean age 62 years) with clinical suspicion of PE explored by HCT were studied. The patients were separated into three different groups according to clinical severity and treatment decisions: group SPE included patients with severe PE based on clinical data who were treated by fibrinolysis or embolectomy ( n=20); group NSPE included patients with non-severe PE who received heparin ( n=30); and group WPE included patients without PE ( n=31). For each patient we calculated a vascular obstruction index based on the site of obstruction and the degree of occlusion in the pulmonary artery. We noted the HCT signs, i.e., cardiac and pulmonary artery dimensions, that could indicate acute cor pulmonale. According to multivariate analysis, factors significantly correlated with the severity of PE were: the vascular obstruction index (group SPE: 54%; group NSPE: 24%; p<0.001); the maximum minor axis of the left ventricle (group SPE: 30.2 mm; group NSPE: 40.4 mm; p<0.001); the diameter of the central pulmonary artery (group SPE: 32.4 mm; group NSPE: 28.3 mm; p<0.001); the maximum minor axis of the right ventricle (group SPE: 47.5 mm; group NSPE: 42.7 mm; p=0.029); the right ventricle/left ventricle minor axis ratio (group SPE: 1.63; group NSPE: 1.09; p<0.0001). Our data suggest that hemodynamic severity of PE can be assessed on HCT scans by measuring four main criteria: the vascular obstruction index; the minimum diameter of the left ventricle; the RV:LV ratio; and the diameter of the central pulmonary artery.
Collapse
Affiliation(s)
- D Collomb
- Department of Radiology, CHU Grenoble, BP 218, 38043 Grenoble Cedex, France
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Ley S, Kreitner KF, Morgenstern I, Thelen M, Kauczor HU. Bronchopulmonary shunts in patients with chronic thromboembolic pulmonary hypertension: evaluation with helical CT and MR imaging. AJR Am J Roentgenol 2002; 179:1209-15. [PMID: 12388501 DOI: 10.2214/ajr.179.5.1791209] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to compare differences in flow between the pulmonary and systemic circulations by assessing MR phase-contrast flow measurements and CT measurements of dilated bronchial arteries in patients with chronic thromboembolic pulmonary hypertension. MATERIALS AND METHODS Seventeen patients were included in this study. MR phase-contrast flow measurements were used to calculate the net forward volumes in the right and left pulmonary arteries and in the ascending aorta. Single-detector helical CT scans were assessed for the presence of dilated bronchial arteries that could be delineated from the descending aorta to the mainstem bronchi. Their perpendicular cross-sectional area at the level of the main bronchi was measured using a double-threshold region of interest (> or =100-3072 H). RESULTS The mean net forward volume in the aorta was 44.6 mL per heartbeat (R-R interval) and in the pulmonary arteries, 30 mL per R-R interval. Thus, the mean difference was 14.6 mL per R-R interval; this value represents the shunt volume between the systemic arterial and pulmonary venous circulations. On CT, dilated bronchial arteries were depicted in all patients (mean, three arteries per patient). The mean cross-sectional area of the bronchial arteries was 0.19 cm(2). Pearson's correlation coefficient (r) between cross-sectional area and shunt volume was 0.86 (p < 0.01). CONCLUSION MR imaging was able to reveal substantial differences in flow between the systemic arterial and pulmonary venous circulations in patients with chronic thromboembolic pulmonary hypertension. These differences correlated well with the diameters of the bronchial arteries seen on helical CT. Furthermore, these differences resolved after pulmonary thromboendarterectomy. MR imaging enables the accurate estimation of flow in the bronchial arteries in patients with chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
- Sebastian Ley
- Department of Radiology, Langenbeckstr. 1, 55131 Mainz, Germany
| | | | | | | | | |
Collapse
|