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Spampinato MD, Portoraro A, Sofia SM, Luppi F, Benedetto M, D'Angelo L, Galizia G, Fabbri IS, Pagano T, Perna B, Guarino M, Passarini G, Pavasini R, Passaro A, De Giorgio R. The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study. J Ultrasound 2024:10.1007/s40477-024-00874-z. [PMID: 38519765 DOI: 10.1007/s40477-024-00874-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 03/25/2024] Open
Abstract
PURPOSE Pulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM). METHODS This is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h. RESULTS 509 patients (median age 76 years [IQR 67-84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1-4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3-9.8), the D-shape (OR 3.73, 95% CI 1.71-8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72-19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32-22.61) resulted an independent predictor of IHM. CONCLUSION Despite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.
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Affiliation(s)
- Michele Domenico Spampinato
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Andrea Portoraro
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Soccorsa M Sofia
- Emergency Medicine Unit, Emergency department, Maggiore Hospital Bologna, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy.
| | - Francesco Luppi
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Marcello Benedetto
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Luca D'Angelo
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Giorgio Galizia
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Irma Sofia Fabbri
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Teresa Pagano
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Benedetta Perna
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Matteo Guarino
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Giulia Passarini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Angelina Passaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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Nasser MF, Jabri A, Limaye S, Sharma S, Hamade H, Mhanna M, Aneja A, Gandhi S. Echocardiographic Evaluation of Pulmonary Embolism: A Review. J Am Soc Echocardiogr 2023; 36:906-912. [PMID: 37209948 DOI: 10.1016/j.echo.2023.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.
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Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Ahmad Jabri
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Sneha Limaye
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Shorabh Sharma
- Department of Medicine, St. Barnabas Hospital Health System, New York, New York
| | - Hani Hamade
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | | | - Ashish Aneja
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Sanjay Gandhi
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio.
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Impact of Time to Intervention on Catheter-Directed Therapy for Pulmonary Embolism. Crit Care Explor 2023; 5:e0828. [PMID: 36699257 PMCID: PMC9848527 DOI: 10.1097/cce.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Cather-directed therapies (CDTs) are an evolving therapeutic option for patients with intermediate-risk pulmonary embolism (PE). Although many techniques have been studied, there is limited evidence for the impact of timing of intervention on patient outcomes. Our objective was to assess the association between time to CDT in patients presenting with PE on patient-related outcomes such as length of stay (LOS) and mortality. DESIGN Retrospective cohort study. SETTING Single academic center. PATIENTS We identified patients for which the PE response team had been activated from January 2014 to October 2021. Patients were split into two cohorts depending on whether they went to CDT less than 24 hours from admission (early) versus greater than 24 hours (late). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data on demographics, timing of interventions, pulmonary hemodynamics, and outcomes were collected. Sixty-four patients were included in analysis. Thirty-nine (63.8%) underwent their procedure less than 24 hours from admission, whereas 25 (36.2%) underwent the procedure after 24 hours. The time from admission to CDT was 15.9 hours (9.1-20.3 hr) in the early group versus 33.4 (27.9-41) in the late group (p ≤ 0.001). There was a greater decrease in pulmonary artery systolic pressure after intervention in the early cohort (14 mm Hg [6-20 mm Hg] vs 6 mm Hg [1-10 mm Hg]; p = 0.022). Patients who received earlier intervention were found to have shorter hospital LOS (4 vs 7 d; p = 0.038) and ICU LOS (3 vs 5 d; p = 0.004). There was no difference in inhospital mortality between the groups (17.9% vs 12%; p = 0.523). CONCLUSIONS Patients who underwent CDT within 24 hours of admission were more likely to have shorter hospital and ICU LOS. The magnitude of change in LOS between the two cohorts was not fully explained by the difference in time to CDT. There were modest improvements in pulmonary hemodynamics in the patients who underwent CDT earlier.
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Prosperi-Porta G, Ronksley P, Kiamanesh O, Solverson K, Motazedian P, Weatherald J. Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis. Eur Respir Rev 2022; 31:31/166/220120. [PMID: 36198416 DOI: 10.1183/16000617.0120-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND We sought to determine the prognostic value of transthoracic echocardiography (TTE)-derived right ventricular dysfunction (RVD) in haemodynamically stable and intermediate-risk patients with acute pulmonary embolism (PE), evaluate continuous RVD parameters, and assess the literature quality. METHODS We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials for studies assessing TTE-derived RVD in haemodynamically stable PE that reported in-hospital adverse events within 30 days. We determined pooled odds ratios (ORs) using a random-effects model, created funnel plots, evaluated the Newcastle-Ottawa scale and performed Grading of Recommendations, Assessment, Development and Evaluation. RESULTS Based on 55 studies (17 090 patients, 37.8% RVD), RVD was associated with combined adverse events (AEs) (OR 3.29, 95% confidence interval (CI) 2.59-4.18), mortality (OR 2.00, CI 1.66-2.40) and PE-related mortality (OR 4.01, CI 2.79-5.78). In intermediate-risk patients, RVD was associated with AEs (OR 1.99, CI 1.17-3.37) and PE-related mortality (OR 6.16, CI 1.33-28.40), but not mortality (OR 1.63, CI 0.76-3.48). Continuous RVD parameters provide a greater spectrum of risk compared to categorical RVD. We identified publication bias, poor methodological quality in 34/55 studies and overall low certainty of evidence. CONCLUSIONS RVD is frequent in PE and associated with adverse outcomes. However, data quality and publication bias are limitations of existing evidence.
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Affiliation(s)
| | - Paul Ronksley
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Omid Kiamanesh
- Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pouya Motazedian
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jason Weatherald
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada .,Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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López-Candales A, Vallurupalli S. Utility of the tricuspid annular tissue doppler systolic velocity and pulmonary artery systolic pressure relationship in right ventricular systolic function assessment: A pilot study. Echocardiography 2022; 39:1276-1283. [PMID: 36100955 DOI: 10.1111/echo.15441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/15/2022] [Accepted: 08/09/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has been validated as a valuable noninvasive measure of right ventricular (RV) elastance and systolic function. However, the more reliable TA systolic (s') velocity measure of RV systolic function compared to TAPSE has not been previously studied. METHODS We conducted a pilot study using several variables of RV function in 50 patients with the main aim to determine which numerical expression between TA TDI s'/PASP and TAPSE/PASP ratio was most useful. RESULTS In a stepwise multiple regression analysis, TA TDI s'/PASP ratio (p < .0002); LVOT VTI/RVOT VTI ratio (p < .0002); RVOT VTI (p < .0047); TAPSE/PASP ratio (p < .0259) and TA TDI e' (p < .0292) were best in discriminating normal versus abnormal RV systolic function. Using receiver operator curve analysis, cut-off values for both TA TDI s'/PASP (>3.9 mm/c/mmHg) had 82.1% sensitivity and 77.3% specificity while the TAPSE/PASP (>.61 mm/mmHg) had 89.3% sensitivity and 68.2% specificity in identifying normal RV function in our studied population. CONCLUSION Our results indicate that TA TDI s'/PASP is a better mathematical expression when examining the relationship between RV contractility and RV resistance relationship. Furthermore, we also found that inclusion of RVOT VTI, RV diastolic properties, and left ventricular systolic function are important determinants of RV systolic function assessments and should be routinely included. Additional prospective studies are now needed to confirm these results using hemodynamic data.
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Affiliation(s)
- Angel López-Candales
- Cardiovascular Medicine Division, University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Srikanth Vallurupalli
- Cardiology Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Ventricular-arterial decoupling is associated with in-hospital adverse events in normotensive pulmonary embolism. Int J Cardiovasc Imaging 2022; 38:2655-2665. [DOI: 10.1007/s10554-022-02677-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/16/2022] [Indexed: 12/20/2022]
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Left Ventricle Outflow Tract Velocity-Time Index and Right Ventricle to Left Ventricle Ratio as Predictors for in Hospital Outcome in Intermediate-Risk Pulmonary Embolism. Diagnostics (Basel) 2022; 12:diagnostics12051226. [PMID: 35626382 PMCID: PMC9139934 DOI: 10.3390/diagnostics12051226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/10/2022] Open
Abstract
Accurate estimation of risk with both imaging and biochemical parameters in intermediate risk pulmonary embolism (PE) remains challenging. The aim of the study was to evaluate echocardiographic parameters that reflect right and left heart hemodynamic as predictors of adverse events in intermediate risk PE. This was a retrospective observational study on patients with computed tomography pulmonary angiography diagnosis of PE admitted at Cardiology department of the Clinical Emergency Hospital of Oradea, Romania between January 2018—December 2021. Echocardiographic parameters obtained at admission were studied as predictors of in hospital adverse events. The following adverse outcomes were registered: death, resuscitated cardiac arrest, hemodynamic deterioration and need of rescue thrombolysis. An adverse outcome was present in 50 patients (12.62%). PE related death was registered in 17 patients (4.3%), resuscitated cardiac arrest occurred in 6 patients (1.51%). Another 20 patients (5.05%) required escalation of therapy with thrombolysis and 7 (1.76%) patients developed haemodynamic instability. Echocardiographic independent predictors for in hospital adverse outcome were RV/LV ≥ 1 (HR = 3.599, 95% CI 1.378−9.400, p = 0.009) and VTI ≤ 15 mm (HR = 11.711, 95% CI 4.336−31.633, p < 0.001). The receiver operator curve renders an area under curve for LVOT VTI ≤ 15 mm of 0.792 (95% CI 0.719−0.864, p < 0.001) and for a RV/LV ≥ 1 of 0.746 (95% CI 0.671−0.821, p < 0.001). A combined criterion (LVOT VTI ≤ 15 and RV/LV ≥ 1) showed a positive predictive value of 75% and a negative predictive value of 95% regarding in hospital adverse outcomes. Low LVOT VTI and increased RV/LV are useful for identifying normotensive patients with PE at risk for short term adverse outcomes. Combining an LVOT VTI ≤ 15 cm with a RV/LV ≥ 1 can identify with increased accuracy PE patients with impending risk of clinical deterioration.
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