Short term clinical outcome of acute saddle pulmonary embolism

Saddle Pulmonary Embolism in Patients with Cancer in the Era of Incidental Events: Clinical Findings and Outcomes in a Single Centre Cohort

Background  There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer. Objectives  This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events. Patients/Methods  Consecutive patients with cancer-related PE (March 1, 2006-October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE. Results  Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%; p =0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%; p =0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%; p <0.001) and interventricular septum displacement (53 vs. 20%; p <0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE. Conclusion  Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.

Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics

The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P= .001), and tachypnea (58.9% vs. 42.1%, P= .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P= .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P= .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P= .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P= .000), RV dysfunction (45.8% vs. 22%, P= .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P= .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P= .864) and hypoxemia (41.1% vs. 34.3%, P= .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.

Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

BACKGROUND

There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study.

METHODS

A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis.

RESULTS

Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively).

CONCLUSIONS

Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.

Asthma Exacerbation Coincident with Saddle Pulmonary Embolism and Paradoxical Embolism

Saddle pulmonary embolism (PE) and paradoxical embolism (PDE) are life-threatening disorders carrying a risk of sudden death, and their prompt diagnosis is extremely important. Saddle PE is a radiologic definition and refers to a thrombus that straddles the bifurcation of the pulmonary artery trunk, carrying a risk of sudden hemodynamic collapse. PDE is defined as a systemic arterial embolus due to the passage of a venous thrombus though a right-to-left shunt, such as patent foramen ovale (PFO). We herein present the rare case of asthma exacerbation coincident with saddle PE and PDE. A 69-year-old woman with asthma was suffering from dyspnea, pulse attenuation of the left radial artery and left upper limb pain. An arterial blood gas analysis revealed hypoxemia, and a pulmonary function test demonstrated an obstructive pattern. Enhanced computed tomography (CT) revealed saddle PE, right popliteal venous thrombosis, and left brachial artery occlusion. After the treatment with edoxaban, an anticoagulant, and aspirin, the PE was significantly alleviated, and the brachial artery occlusion was recanalized. Subsequently, the right-to-left shunt through PFO was confirmed, and PDE was suspected of inducting her brachial artery embolism. In the present case, the pulse attenuation of the radial artery and upper limb pain prompted us to consider peripheral vascular disease or coagulation disorders. Physicians should keep in mind that patients with asthma are at considerable risk of PE, and it is important to be aware of possible PFO in patients presenting with the coexistence of PE and systemic arterial embolism.

Saddle vs Nonsaddle Pulmonary Embolism: Clinical Presentation, Hemodynamics, Management, and Outcomes

OBJECTIVE

To understand the clinical significance, hemodynamic presentation, management, and outcomes of patients presenting with saddle pulmonary embolism (PE).

METHODS

All patients with saddle PE diagnosed at Mayo Clinic in Rochester, Minnesota, from January 1, 1999, through December 31, 2014, were included in this study. These patients were age and simplified Pulmonary Embolism Severity Index (sPESI) matched (1:1) to a nonsaddle PE cohort. Both groups were then classified into massive, submassive, and low-risk PE based on established criteria and compared for clinical presentation, management, and outcomes.

RESULTS

A total of 187 consecutive patients with saddle PE were identified. The saddle PE group presented more frequently with massive PE (31% vs 20%) and submassive PE (49% vs 32%), whereas low-risk PE was more common in the nonsaddle PE group (48% vs 20%). Systemic thrombolysis was used more frequently in the saddle PE group on admission (10% vs 4%; P=.04) and later during hospitalization (3.2% vs 0%; P=.03). Late major adverse events were similar in both groups except for mechanical ventilation (6% in saddle PE vs 1% in nonsaddle PE; P=.02). Overall in-hospital mortality did not differ between the 2 groups (4.3% in saddle PE vs 5.4% in nonsaddle PE; P=.81).

CONCLUSION

Although patients with saddle PE presented with higher rates of hemodynamic compromise and need for thrombolysis and mechanical ventilation, we found no difference in short-term outcomes compared with an age- and severity-matched nonsaddle PE cohort. Overall, in-hospital mortality was low in both groups.

Computed Tomographic Pulmonary Angiographic Findings Can Predict Short-Term Mortality of Saddle Pulmonary Embolism: A Retrospective Multicenter Study

OBJECTIVE

In patients with saddle pulmonary embolism (PE), the correlation between computed tomographic pulmonary angiographic (CTPA) findings and short-term outcome remains unclear. The purpose is to determine if CTPA findings predict 1-month mortality of patients with saddle PE.

METHODS

This is a multicenter, retrospective study of saddle PE. Computed tomographic pulmonary angiographic findings of 115 consecutive patients (male-to-female ratio, 65:50; mean age, 64.3 ± 16.3 years) with saddle PE were evaluated. One-month mortality after diagnosis was the primary end point.

RESULTS

Twenty-four patients died within 1 month. Among CTPA findings, quantitative parameters including right/left ventricular area ratios (RVa/LVa), right/left atrial diameter ratios, Cobb angle, and Mastora score were significantly enlarged in survivors. Also, qualitative findings including contrast agent reflux into the azygos vein and pericardial effusion were significantly different between survivors and nonsurvivors. Areas under the curve on receiver operating characteristic curves revealed the cutoff values for predicting early mortality of saddle PE using right/left atrial diameter ratios, RVa/LVa, Mastora score, and Cobb angle, respectively, were 2.15, 2.00, 69%, and 58°. Logistic regression analysis suggested that both RVa/LVa (odds ratio, 5.100; P = 0.0004) and Cobb angle (odds ratio, 1.596; P = 0.0321) were independent predictors of early mortality. The combination of RVa/LVa and Cobb angle increased the area under the curve to 0.882, but the difference did not reach significance compared with RVa/LVa or Cobb angle, alone (P > 0.05).

CONCLUSION

In patients with saddle PE, RVa/LVa and Cobb angle seem valuable in predicting short-term mortality.

Saddle Pulmonary Embolism: Laboratory and Computed Tomographic Pulmonary Angiographic Findings to Predict Short-term Mortality

BACKGROUND

Saddle pulmonary embolism (SPE) is rare type of acute pulmonary embolism and there is debate about its treatment and prognosis. Our aim is to assess laboratory and computed tomographic pulmonary angiographic (CTPA) findings to predict short-term mortality in patients with SPE.

METHODS

This was a five-centre, retrospective study. The clinical information, laboratory and CTPA findings of 88 consecutive patients with SPE were collected. One-month mortality after diagnosis of SPE was the primary end-point. The correlation of laboratory and CTPA findings with one-month mortality was analysed with area under curve (AUC) of receiver operating characteristic (ROC) curves and logistic regression analysis.

RESULTS

Eighteen patients with SPE died within one month. Receiver operating characteristic curves revealed that the cutoff values for the right and left atrial diameter ratio, the right ventricular area and left ventricular area ratio (RVa/LVa ratio), Mastora score, septal angle, N-terminal pro-brain natriuretic peptide and cardiac troponin I (cTnI) for detecting early mortality were 2.15, 2.13, 69%, 57°, 3036 pg/mL and 0.18ng/mL, respectively. Using logistic regression analysis of laboratory and CTPA findings with regard to one-month mortality of SPE, RVa/LVa ratio and cTnI were shown to be independently associated with early death. A combination of cTnI and RVa/LVa ratio revealed an increase in the AUC value, but the difference did not reach significance compared with RVa/LVa or cTnI, alone (P>0.05).

CONCLUSION

In patients with SPE, both the RVa/LVa ratio on CTPA and cTnI appear valuable for the prediction of short-term mortality.

Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta-analysis

BACKGROUND

In patients with acute pulmonary embolism (PE), risk stratification is indicated for tailoring of both diagnostic strategies and acute treatment. Whether embolic burden assessed at computed tomography (CT) angiography has a role in risk stratification in these patients is debated.

OBJECTIVE

To systematically review and perform a meta-analysis to evaluate the role of CT-assessed burden associated with embolic obstruction and embolic localization in the prognostic stratification of patients with acute PE.

METHODS

We performed a systematic search in EMBASE and MEDLINE up until 30 June 2013. Studies reporting on the 30-day outcome of patients with confirmed PE and CT-assessed embolic burden were included. The study outcome was death.

RESULTS

Thirty studies reporting on the prognostic value of CT-assessed embolic burden met the inclusion criteria for this systematic review; of these, 19 were included in the meta-analysis. Five studies (2215 patients) were included in the analysis of localization: an association between embolus localization in the central arteries and 30-day mortality was found after heterogeneity was resolved (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.29-3.89, I(2)  = 0%). No correlation was observed between obstruction index (according to the Qanadli scoring system) and 30-day mortality after heterogeneity was reduced (16 studies, 3884 patients, OR 1.22, 95% CI 0.99-1.51, I(2)  = 27%).

CONCLUSION

Localization of emboli assessed at CT angiography can be used for risk stratification in patients with acute PE. Moreover, no correlation was observed between obstruction index and prognosis.

The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism

OBJECTIVE

Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE.

METHODS

In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined.

RESULTS

Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01).

CONCLUSION

At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE.

ADVANCES IN KNOWLEDGE

The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE.

Multidetector CT scan for acute pulmonary embolism: embolic burden and clinical outcome

BACKGROUND

In patients with acute pulmonary embolism (PE), the correlation between the embolic burden assessed by multidetector CT (MDCT) scan and clinical outcomes remains unclear. Patients with symptomatic acute PE diagnosed based on MDCT angiography were included in a multicenter study aimed at assessing the prognostic role of the embolic burden evaluated with MDCT scan.

METHODS

Embolic burden was assessed as (1) localization of the emboli as central (saddle or at least one main pulmonary artery), lobar, or distal (segmental or subsegmental arteries) and (2) the obstruction index by the scoring system of Qanadli. The primary outcome was 30-day all-cause death or clinical deterioration. Predictors of all-cause death or clinical deterioration were identified by Cox regression statistics.

RESULTS

Overall, 579 patients were included in the study; 60 (10.4%) died or had clinical deterioration at 30 days. Central localization of emboli was not associated with all-cause death or clinical deterioration (hazard ratio [HR], 2.42; 95% CI, 0.77-7.59; P 5 .13). However, in 516 hemodynamically stable patients, central localization of emboli (HR, 8.3; 95% CI, 1.0-67; P 5 .047) was an independent predictor of all-cause death or clinical deterioration, whereas distal emboli were inversely associated with these outcome events (HR, 0.12; 95% CI, 0.015-0.97; P 5 .047). No correlation was found between obstruction index (evaluated in 448 patients) and all-cause death or clinical deterioration in the overall study population and in the hemodynamically stable patients.

CONCLUSIONS

In hemodynamically stable patients with acute PE, central emboli are associated with an increased risk for all-cause death or clinical deterioration. This risk is low in patients with segmental or subsegmental PE.

Saddle pulmonary embolism: is it as bad as it looks? A community hospital experience

BACKGROUND

Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients.

OBJECTIVE

To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%).

CONCLUSIONS

Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

Acute saddle pulmonary embolism in Ewing sarcoma

Two young adults had similar presentations of Ewing sarcoma, with spinal cord involvement and significant neurologic deficits. Shortly after workup, stabilization, and initiation of chemotherapy, both developed acute saddle pulmonary embolism, despite prophylactic anticoagulation. In both cases, prompt intravenous thrombolysis and therapeutic anticoagulation successfully managed this complication. Review of the presentation, treatment options, and most current guidelines for acute saddle pulmonary embolism follow the case presentations.

Asymptomatic Saddle Pulmonary Embolism: Case Report and Literature Review

Saddle pulmonary embolism is defined as a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Patient with saddle pulmonary embolism have a 2-week mortality of 5.8%. 46 years old, hypertensive male, presented with right leg swelling and pain, with no evidence of cardiopulmonary distress. CTA showed a large saddle pulmonary embolus. Doppler ultrasound of right lower extremity, revealed a large filling defect extending from the common femoral vein distally involving the deep femoral vein, femoral vein and popliteal vein on the right.

Diagnosis of saddle embolus on its own is not associated with an unfavorable outcome, therefore should not influence management of PE. Echocardiography done within 48hours in-patient with symptomatic saddle pulmonary embolism reveals mild to moderate right ventricular enlargement in 90% and mild to severe right ventricular dysfunction in 80%. Emerging evidence suggest that primary therapy with thrombolytics and embolectomy, should be used in PE patients who presents with hypotension plus moderate to severe right ventricular dysfunction on echo cardiogram.

Patients with saddle pulmonary embolism can have normal cardiopulmonary reserve; these patients can be managed with conventional treatment for pulmonary embolism in hospital settings, in order to deal with any complications developed during management. Aggressive management should be reserved for patients who are hemodynamically unstable as well as those with echocardiographic evidence of severe right ventricular strain. Physicians should decrease their threshold for suspicion of pulmonary embolism in patients with deep venous thrombosis in the hope of revealing more and more hidden cases of pulmonary embolism.

Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome

OBJECTIVE

To assess the frequency, clinical presentation and outcome associated with saddle pulmonary embolism (PE) diagnosed by computed tomographic angiography (CTA).

PATIENTS

Retrospective review of 546 consecutive patients diagnosed to have acute PE by CTA from 1 September 2002 to 31 December 2003.

RESULTS

Fourteen of 546 patients (2.6%) had saddle PE; 10 were men (71%). None of these patients had pre-existing cardiopulmonary disease. Most common presenting symptoms included dyspnea (72%) and syncope (43%). Hypotension was documented in 2 patients (14%). The most common risk factor for PE was obesity (64%). CTA revealed saddle PE and additional filling defects in the main pulmonary arteries in all patients. Echocardiography was performed within 48 h of the PE diagnosis in 10 patients and revealed right ventricular dysfunction in 8 (80%). All patients were initially managed in the hospital, median length of stay of 4 days (range, 1-45 days). Standard anticoagulant therapy with heparin and warfarin was administered to all patients. Five patients (36%) received additional therapy; thrombolytic therapy was administered to 1 patient (7%) and 4 patients (29%) received an inferior vena cava filter. None of the patients died during their hospitalization. Four patients (29%) died following their hospitalization after intervals of 1, 5, 6, and 12 months, respectively. Causes of death were known in 3 patients, all of whom died from progressive malignancy.

CONCLUSION

Saddle PE in patients without pre-existing cardiopulmonary disease is associated with a relatively low in-hospital mortality rate and may not necessitate aggressive medical management.