Submassive Pulmonary Embolism

Validation of the PEACE score for predicting abnormal echocardiographic findings in pulmonary embolism patients

BACKGROUND

Pulmonary embolism (PE) is a life-threatening condition requiring rapid risk stratification for optimal management. The Pulmonary Embolism Advanced Cardiac Evaluation (PEACE) Score is a novel tool integrating clinical, laboratory, and echocardiographic parameters to assess disease severity. This study aimed to evaluate the correlation between PEACE Score and echocardiographic abnormalities in PE patients, and to determine its effectiveness as a rapid risk assessment tool in emergency settings.

METHODS

Between June 2020 and June 2024, 120 patients were prospectively screened and enrolled in the study after being diagnosed with pulmonary embolism via CT angiography in the emergency department. Patients were categorized into three groups according to PEACE score as low risk (< 3 points, n = 42), intermediate risk (3-5 points, n = 52) and high risk (> 5 points, n = 26). Echocardiographic findings were not used for stratification but rather analyzed as outcome variables to assess the discriminative validity of the PEACE Score. Demographic data, laboratory findings and echocardiographic parameters were recorded. Patients were followed up for at least 1 year. Follow-up from 3 months to 6 months was evaluated and mortality rates at the end of 1 year were determined.

RESULTS

PEACE Score was strongly correlated with echocardiographic abnormalities (r = 0.685, p < 0.001) and inflammatory markers, including CRP (r = 0.524, p < 0.001). The PEACE Score had the highest diagnostic value for predicting echocardiographic abnormalities, with an AUC of 0.82 (95% CI: 0.74-0.90, p < 0.001). Specifically, in predicting right ventricular dysfunction, the PEACE Score achieved an AUC of 0.85 (95% CI: 0.77-0.93, p < 0.001). A cutoff of > 5 points showed a sensitivity of 84.6% and specificity of 79.2% for detecting severe echocardiographic abnormalities. One-year survival rates were 45% in the high-risk group, 65% in the intermediate-risk group, and 85% in the low-risk group. Kaplan-Meier analysis confirmed significant differences in survival among risk groups (p < 0.001).

CONCLUSION

The PEACE Score demonstrated a strong association with echocardiographic abnormalities and patient survival in emergency department PE cases. These findings suggest that PEACE may serve as a valuable tool for rapid risk stratification, aiding emergency physicians in early clinical decision-making. Specifically, high PEACE Scores were associated with a greater need for thrombolytic therapy and ICU admission, suggesting its potential utility in guiding treatment escalation and resource allocation in critically ill PE patients.

CLINICAL TRIAL NUMBER

Not applicable.

Positive association between stress hyperglycemia ratio and ICU mortality in patients with pulmonary embolism: A retrospective study

BACKGROUND

Measurement of the Stress Hyperglycemia Ratio (SHR) aims to reduce the influence of prolonged chronic glycemic variables on stress hyperglycemia levels, which are associated with clinical outcomes. Nevertheless, the correlation between SHR and the risk of all-cause Intensive Care Unit (ICU) mortality in patients with pulmonary embolism(PE) remains unclear.

METHODS

Data for this retrospective study were o btained from the MIMIC IV2.2 database. The participants were divided into four groups based on the SHR quartiles. The primary outcome measured was 28-day ICU mortality. We employed Cox proportional hazards regression analysis and restricted cubic splines to evaluate the correlation between the SHR and clinical outcomes in patients with PE.

RESULTS

The study included 1185 patients, of which 53.3% were male. The rates of mortality observed in the ICU were 19.8%. By conducting multivariable Cox proportional hazards, it was determined that the SHR was independently associated with a heightened risk of 28-day ICU mortality (HR = 1.83 per 1-point increment, 95% CI = 1.07-3.13, p = 0.028).The analysis using restricted cubic splines showed that there was a consistent and gradually increasing risk of all-cause mortality as the SHR increased. This indicates that a higher SHR is associated with a higher risk of ICU mortality.

CONCLUSIONS

Elevated SHR was strongly linked to a higher risk of clinical outcomes in patients with PE. As an effective measure of stress hyperglycemia, SHR demonstrated superior performance in predicting risks compared to solely evaluating glycemia or HbA1c upon admission.

A risk prediction model for venous thromboembolism in hospitalized patients with thoracic trauma: a machine learning, national multicenter retrospective study

BACKGROUND

Early treatment and prevention are the keys to reducing the mortality of VTE in patients with thoracic trauma. This study aimed to develop and validate an automatic prediction model based on machine learning for VTE risk screening in patients with thoracic trauma.

METHODS

In this national multicenter retrospective study, the clinical data of chest trauma patients hospitalized in 33 hospitals in China from October 2020 to September 2021 were collected for model training and testing. The data of patients with thoracic trauma at Shanghai Sixth People's Hospital from October 2021 to September 2022 were included for further verification. The performance of the model was measured mainly by the area under the receiver operating characteristic curve (AUROC) and the mean accuracy (mAP), and the sensitivity, specificity, positive predictive value, and negative predictive value were also measured.

RESULTS

A total of 3116 patients were included in the training and validation of the model. External validation was performed in 408 patients. The random forest (RF) model was selected as the final model, with an AUROC of 0·879 (95% CI 0·856-0·902) in the test dataset. In the external validation, the AUROC was 0.83 (95% CI 0.794-0.866), the specificity was 0.756 (95% CI 0.713-0.799), the sensitivity was 0.821 (95% CI 0.692-0.923), the negative predictive value was 0.976 (95% CI 0.958-0.993), and the positive likelihood ratio was 3.364.

CONCLUSIONS

This model can be used to quickly screen for the risk of VTE in patients with thoracic trauma. More than 90% of unnecessary VTE tests can be avoided, which can help clinicians target interventions to high-risk groups and ensure resource optimization. Although further validation and improvement are needed, this study has considerable clinical value.

Economic Analysis of Catheter-Directed Thrombolysis for Intermediate-Risk Pulmonary Embolism

BACKGROUND

Pulmonary embolism is associated with a significant burden of morbidity, mortality, and health care costs. Catheter-directed thrombolysis has emerged as a promising option for patients with intermediate-risk pulmonary embolism which aims to improve outcomes over standard anticoagulation.

METHODS

We constructed a decision-analytic model comparing the cost-effectiveness of catheter-directed thrombolysis to anticoagulation alone for the management of intermediate-risk pulmonary embolism. Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios (ICER). Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. The main outcome was ICER (US dollars/deaths averted).

RESULTS

In the base case analysis, derived using systemic lysis data, the cost associated with catheter-directed thrombolysis was estimated at $22,353 with a probability of survival at 1 month of 0.984. For the anticoagulation alone strategy, the cost was $25,060, and the probability of survival at 1 month was 0.958. Overall, catheter-directed thrombolysis resulted in savings of $104,089 per death averted (ICER,-$104,089 per death averted). Sensitivity analysis revealed that catheter-directed thrombolysis would no longer be cost-effective when its associated mortality is greater than 0.042. In the probabilistic analysis, at a willingness-to-pay of $100,000, catheter-directed thrombolysis had a 63% chance of being cost-effective, and in cost-effectiveness acceptability curves, it was cost-effective in 63%-78% of simulations for a willingness to pay ranging from $0 to $100,000.

CONCLUSIONS

If the assumptions made in our model are shown to be accurate then CDT would be cost-effective and may lead to considerable cost savings if used where clinically appropriate.

Prediction of pulmonary embolism by an explainable machine learning approach in the real world

In recent years, large amounts of researches showed that pulmonary embolism (PE) has become a common disease, and PE remains a clinical challenge because of its high mortality, high disability, high missed and high misdiagnosed rates. To address this, we employed an artificial intelligence-based machine learning algorithm (MLA) to construct a robust predictive model for PE. We retrospectively analyzed 1480 suspected PE patients hospitalized in West China Hospital of Sichuan University between May 2015 and April 2020. 126 features were screened and diverse MLAs were utilized to craft predictive models for PE. Area under the receiver operating characteristic curves (AUC) were used to evaluate their performance and SHapley Additive exPlanation (SHAP) values were utilized to elucidate the prediction model. Regarding the efficacy of the single model that most accurately predicted the outcome, RF demonstrated the highest efficacy in predicting outcomes, with an AUC of 0.776 (95% CI 0.774-0.778). The SHAP summary plot delineated the positive and negative effects of features attributed to the RF prediction model, including D-dimer, activated partial thromboplastin time (APTT), fibrin and fibrinogen degradation products (FFDP), platelet count, albumin, cholesterol, and sodium. Furthermore, the SHAP dependence plot illustrated the impact of individual features on the RF prediction model. Finally, the MLA based PE predicting model was designed as a web page that can be applied to the platform of clinical management. In this study, PE prediction model was successfully established and designed as a web page, facilitating the optimization of early diagnosis and timely treatment strategies to enhance PE patient outcomes.

Clinical Outcomes of Catheter-Directed Thrombolysis versus Mechanical Aspiration in Patients with Acute Pulmonary Embolism

PURPOSE

The objective of this study was to evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) and mechanical aspiration (MA) for acute pulmonary embolism (PE).

METHODS

From February 2022 to October 2024, the clinical data of patients with high- and intermediate-risk PE who received endovascular therapy were retrospectively reviewed. Patients were categorized based on the treatment strategy.

RESULTS

Fifty-eight consecutive patients were identified. CDT was initiated in 29 patients, while the remaining 29 received MA treatment. The time of thrombolysis and the dosage of urokinase were both lower in the MA group (P <0.05). No differences were found in cardiac biomarkers after 48 hours, perioperative bleeding events, heart/valve injury, and mortality. The total cost of the MA group was much higher compared to CDT alone. The MA group showed better improvement in right ventricular (RV) function with a higher reduction in the right ventricular-to-left ventricular ratio (0.55 ± 0.46 vs. 0.13 ± 0.53, P = 0.017). No differences were found in the reduction of the CT obstruction index.

CONCLUSION

CDT and MA seem to have similar outcomes for patients with acute high- and intermediate-risk PE. MA is more effective in improving RV function with less thrombolysis time and fewer thrombolytics.

Causal association between epigenetic age acceleration and two pulmonary vascular diseases: pulmonary arterial hypertension and pulmonary embolism-a bidirectional Mendelian study

BACKGROUND

Pulmonary arterial hypertension (PAH) is a relatively rare but severe disease with a poor prognosis. Pulmonary embolism (PE) is a serious condition that can cause sudden death. Epigenetic age acceleration (EAA) is a robust indicator derived from the DNA methylation-based epigenetic clock, which can predict the extent of aging. It has been proved that the epigenetic clock and EAA are associated with many cardiovascular diseases, while their associations with PAH and PE remain inconclusive. Our study aims to investigate the associations among these factors.

METHOD

By harnessing summary-level data from large-scale genome-wide association studies (GWAS), we designed a two-sample bidirectional Mendelian randomization (MR) analysis to assess the causal associations between measures of three epigenetic clocks, including GrimAge acceleration (n = 34,467), Hannum Age acceleration (n = 34,449) and PhenoAge acceleration (n = 34,463) and PAH (including 125 cases and 162,837 controls), as well as PE (including 3940 cases and 480,658 controls). The inverse variance-weighted (IVW) method was used as the primary method for MR analysis. Other methods, such as MR egger and weighted mode, served as complements to the IVW approach, were also applied in the analyses. Then, the MR pleiotropy test and MR-PRESSO test, which are effective tools for quality control of MR analysis, were subsequently used to ensure the accuracy of the study.

RESULTS

The forward MR analysis indicated that all three epigenetic clocks had no significant effects on PAH or PE. The reverse analysis indicated that the onset and progression of PAH and PE had insignificant effects on three epigenetic clocks. The results of the quality control assessment confirmed that our findings were reliable.

CONCLUSION

Our two-sample bidirectional MR analysis suggested that there is no significant association between epigenetic clocks and these two pulmonary vascular diseases.

NUPR1 modulates pulmonary embolism progression via smooth muscle cells phenotypic transformation

Objective

This study aimed to investigate the role of Nuclear Protein 1 (NUPR1) in pulmonary embolism (PE) and its impact on the phenotypic transformation of pulmonary artery smooth muscle cells (PASMCs).

Methods

A PE model was established via autologous pulmonary emboli infusion into the jugular vein. Partial Pressure of Oxygen (PaO2), Oxygenation Index (OI), Brain Natriuretic Peptide (BNP), and Troponin I (TnI) were measured, and lung tissue was subjected to hematoxylin-eosin (HE) staining. NUPR1 expression was assessed through Immunofluorescence and Western blot analyses. To investigate role of NUPR1, PE rats were treated with lentiviral vectors for NUPR1 knockdown (si-NUPR1) or overexpression (ov-NUPR1), and the effects on lung pathology were examined. NUPR1 expression was evaluated in human PASMCs. Additionally, PASMCs from SD rats were cultured under normoxic and hypoxic conditions to evaluate NUPR1 expression. Transfection of NUPR1 expression vectors into PASMCs allowed monitoring of phenotypic transformation-associated protein changes and PASMCs activity.

Results

Increased NURP1 was observed in human-derived PASMCs. In PE rats, histological examination revealed ruptured pulmonary alveoli, exudate accumulation, interstitial edema, and infiltration of inflammatory cells, concomitant with elevated NUPR1 expression levels. Knockdown of NUPR1 in PE rats significantly improved lung tissue structure, reducing alveolar rupture and interstitial edema. Conversely, NUPR1 overexpression exacerbated lung damage, leading to increased inflammatory infiltration. NUPR1 expression in rat PASMCs remained stable under normoxic conditions; however, under hypoxic conditions, NUPR1 protein expression increased progressively over time. Subsequent upregulation of NUPR1 expression led to a decrease in the levels of contractile phenotype markers α-SMA and SM22α in PASMCs, accompanied by increased expression of synthetic phenotype markers Vimentin and OPN. This phenotypic shift was associated with enhanced cellular proliferation, invasion, and migration.

Conclusions

Elevated NUPR1 expression in PE exacerbates abnormal PASMCs proliferation by promoting their phenotypic transformation, thereby fostering the pathological progression of PE.

Pathophysiology, diagnosis and management of right ventricular failure: A state of the art review of mechanical support devices

The function of the right ventricle (RV) is to drive the forward flow of blood to the pulmonary system for oxygenation before returning to the left ventricle. Due to the thin myocardium of the RV, its function is easily affected by decreased preload, contractile motion abnormalities, or increased afterload. While various etiologies can lead to changes in RV structure and function, sudden changes in RV afterload can cause acute RV failure which is associated with high mortality. Early detection and diagnosis of RV failure is imperative for guiding initial medical management. Echocardiographic findings of reduced tricuspid annular plane systolic excursion (<1.7) and RV wall motion (RV S' <10 cm/s) are quantitatively supportive of RV systolic dysfunction. Medical management commonly involves utilizing diuretics or fluids to optimize RV preload, while correcting the underlying insult to RV function. When medical management alone is insufficient, mechanical circulatory support (MCS) may be necessary. However, the utility of MCS for isolated RV failure remains poorly understood. This review outlines the differences in flow rates, effects on hemodynamics, and advantages/disadvantages of MCS devices such as intra-aortic balloon pump, Impella, centrifugal-flow right ventricular assist devices, extracorporeal membrane oxygenation, and includes a detailed review of the latest clinical trials and studies analyzing the effects of MCS devices in acute RV failure.

New Diagnostic Tools for Pulmonary Embolism Detection

The presentation of pulmonary embolism (PE) varies from asymptomatic to life-threatening, and management involves multiple specialists. Timely diagnosis of PE is based on clinical presentation, D-dimer testing, and computed tomography pulmonary angiogram (CTPA), and assessment by a Pulmonary Embolism Response Team (PERT) is critical to management. Artificial intelligence (AI) technology plays a key role in the PE workflow with automated detection and flagging of suspected PE in CTPA imaging. HIPAA-compliant communication features of mobile and web-based applications may facilitate PERT workflow with immediate access to imaging, team activation, and real-time information sharing and collaboration. In this review, we describe contemporary diagnostic tools, specifically AI, that are important in the triage and diagnosis of PE.

Hemodynamic Melody of Postnatal Cardiac and Pulmonary Development in Children with Congenital Heart Diseases

Hemodynamics is the eternal theme of the circulatory system. Abnormal hemodynamics and cardiac and pulmonary development intertwine to form the most important features of children with congenital heart diseases (CHDs), thus determining these children's long-term quality of life. Here, we review the varieties of hemodynamic abnormalities that exist in children with CHDs, the recently developed neonatal rodent models of CHDs, and the inspirations these models have brought us in the areas of cardiomyocyte proliferation and maturation, as well as in alveolar development. Furthermore, current limitations, future directions, and clinical decision making based on these inspirations are highlighted. Understanding how CHD-associated hemodynamic scenarios shape postnatal heart and lung development may provide a novel path to improving the long-term quality of life of children with CHDs, transplantation of stem cell-derived cardiomyocytes, and cardiac regeneration.

Randomized controlled trial of mechanical thrombectomy vs catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study

BACKGROUND

The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the pulmonary embolism response team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and nonthrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients.

METHODS

The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a nonrandomized MT cohort for separate analysis. The primary end point will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary end points. Other key secondary end points include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit.

IMPLICATIONS

PEERLESS is the first RCT to compare 2 different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted.

PERT era, race-based healthcare disparities in a large urban safety net hospital

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the United States. Black Americans have higher incidence, greater clot severity, and worse outcomes than White Americans. This disparity is not fully understood, especially in the context of the advent of PE response teams (PERT), which aim to standardize PE-related care. This retrospective single-center cohort study compared 294 Black and 131 White patients from our institution's PERT database. Primary objectives included severity and in-hospital management. Secondary outcomes included length of stay, 30-day readmission, 30-day mortality, and outpatient follow-up. Clot  (p = 0.42), acute treatment (p = 0.28), 30-day mortality (p = 0.77), 30-day readmission (p = 0.50), and outpatient follow-up (p = 0.98) were similar between races. Black patients had a lower mean household income ($35,383, SD 20,596) than White patients ($63,396, SD 32,987) (p < 0.0001). More Black patients (78.8%) had exclusively government insurance (Medicare/Medicaid) compared to White patients (61.8%) (p = 0.006). Interestingly, government insurance patients had less follow-up (58.3%) than private insurance patients (79.7%) (p = 0.001). Notably, patients with follow-up had fewer 30-day readmissions. Specifically, 12.2% of patients with follow-up were readmitted compared to 22.2% of patients without follow-up (p = 0.008). There were no significant differences in PE severity, in-hospital treatment, mortality, or readmissions between Black and White patients. However, patients with government insurance had less follow-up and more readmissions, indicating a socioeconomic disparity. Access barriers such as health literacy, treatment cost, and transportation may contribute to this inequity. Improving access to follow-up care may reduce the disparity in PE outcomes.

Large-Bore Mechanical Thrombectomy of Acute Pulmonary Embolism at a Community-Based Hospital: A Case Series

Acute pulmonary embolism (PE) is a common, and sometimes fatal, diagnosis that results in over 11,000 deaths in hospitalized patients in the USA annually. In patients with high-risk or high-intermediate-risk PE and especially in whom thrombolytic therapy is contraindicated, mechanical thrombectomy can be an effective treatment option. This case series outlines three patients with PE who were successfully treated with large bore aspiration thrombectomy by Interventional Radiology at a community-based military treatment facility (MTF). Two patients had presented to the emergency department with acute PE and a third of patients with acute PE were transferred from an outside hospital specifically for mechanical thrombectomy due to a complication from systemic anticoagulation. The patients were categorized as good candidates for immediate large-bore aspiration thrombectomy, a recently added capability at the MTF. The patients showed immediate improvement post-procedure and required only one night admission for observation to the intensive care unit. Implementation of this new capability for patients with acute high-risk or high-intermediate-risk PE or with contraindications to thrombolysis provides an alternative treatment with immediate, life-saving capability.

The Challenge of Intermediate-Risk Pulmonary Embolism

BACKGROUND

Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established.

AREAS OF UNCERTAINTY

Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions.

THERAPEUTIC ADVANCES

Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions.

CONCLUSIONS

There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.

Be aware of non-specific presentation of pulmonary embolism: a case report

BACKGROUND

The early diagnosis of non-specific presentation of pulmonary embolism (PE) is difficult because the symptoms are non-specific and varied.

CASE PRESENTATION

A 69-year-old female patient had syncope accompanied by gait disturbance, without obvious inducement. The patient was initially suspected to have cerebral infarction, but the symptoms did not improve and myocardial markers increased after two days of symptomatic treatment for myocardial infarction. Hence, PE was suspected and computed tomography pulmonary angiography (CTPA) examination confirmed the diagnosis. CTPA showed multiple emboli in pulmonary artery and its branches, so high-risk PE was diagnosed. Intravenous thrombolysis was administered, and pulmonary CTA showed a significant reduction of emboli in pulmonary artery and its left and right branches.

CONCLUSION

This case report highlights the importance of improving the clinical awareness about non-specific presentation of PE and avoiding misdiagnosis or missed diagnosis.

A bibliometric analysis of the theme trends and knowledge structures of pulmonary embolism from 2017 to 2021

Background

Pulmonary embolism (PE) is a popular area of research in the field of respiratory medicine. We performed a bibliometric analysis based on PubMed database to characterize the distribution pattern of literature and knowledge structures related to PE.

Methods

Literature pertaining to PE from January 1, 2017, to December 31, 2021, was retrieved from the PubMed database. Bibliographic information was generated using the Bibliographic Item Co-Occurrence Matrix Builder (BICOMB). The visualization matrix was established using gCLUTO software. Strategic diagram analysis was performed using GraphPad Prism 9 software. Social network analysis (SNA) was generated using Ucinet6.0 and NetDraw 2.084 software.

Results

Out of all the retrieved MeSH terms and subheadings, 52 MeSH terms/MeSH subheadings with a high frequency were found, and hot subjects were sorted into 6 clusters. The strategy diagram showed that the epidemiology, etiology, and drug therapy of PE were well advanced. In contrast, studies on diagnostic imaging, pathology, and complications of PE were still immature and offered potential research space. Social network analysis showed that marginal topics such as surgical treatment of pulmonary hypertension, prevention and control of postoperative complications, and metabolism and analysis of fibrin/fibrinogen degradation products were emerging research hotspots.

Conclusion

Objective analysis of the research developments in the field of PE can provide intuitive knowledge structure for researchers and clinicians. Analysis of the research hotspots related to PE is helpful for researchers and clinicians by highlighting future research directions.

Massive pulmonary embolism and intra-cardiac thrombus requiring systemic thrombolysis 9-hours post emergency laparotomy

The link between abdominal surgery and venous thromboembolism (VTE) has been well established with recent evidence exploring the optimal VTE risk reducing strategy. However, despite these strategies pulmonary embolisms (PEs) do occur, which in the immediate post-operative setting creates a dilemma; to treat the VTE with anticoagulation but balance against the risk of hemorrhage. Treatment guidelines often do not include post-operative patients leaving the decision up to the treating physician to weigh the relative risks on an individual basis. We present a 59-year-old lady who developed a life-threatening submassive PE within 9 h of an emergency laparotomy for a perforated rectal cancer. She was treated with systemic thrombolysis after alternative interventions had been excluded. She responded well to therapy with no major bleeding. She was successfully discharged home after a short period of inpatient rehabilitation.

Sex Differences in Management and Outcomes Among Patients With High-Risk Pulmonary Embolism: A Nationwide Analysis

OBJECTIVE

To examine the sex differences in management and outcomes among patients with high-risk acute pulmonary embolism (PE).

PATIENTS AND METHODS

The Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2018. Differences in use of advanced therapies, in-hospital mortality, and bleeding events were compared between men and women.

RESULTS

A total of 125,901 weighted hospitalizations with high-risk PE were identified during the study period; 46.3% were women (n=58,253). Women were older and had a higher prevalence of several comorbidities and risk factors of PE such as morbid obesity, diabetes mellitus, chronic pulmonary disease, heart failure, and metastatic cancer. Systemic thrombolysis and catheter-directed interventions were more commonly used among women; however, mechanical circulatory support was less frequently used. In-hospital mortality was higher among women in the unadjusted analysis (30.7% vs 27.8%, P<.001) and after propensity score matching (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 to 1.25; P<.001), whereas the rates of intracranial hemorrhage and non-intracranial hemorrhage were not different. On multivariate regression analysis, female sex (OR, 1.18; 95% CI, 1.15 to 1.21; P<.001) was independently associated with increased odds of in-hospital mortality.

CONCLUSION

In this contemporary observational cohort of patients admitted with high-risk PE, women had higher rates of in-hospital mortality despite receiving advanced therapies more frequently, whereas the rate of major bleeding events was not different from men. Efforts are needed to minimize the excess mortality observed among women.

Development of Risk Prediction Model for Muscular Calf Vein Thrombosis with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

This study aims to establish a risk prediction model for muscular calf vein thrombosis (MCVT) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

The research sample consisted of 248 patients with AECOPD and all of them underwent vascular ultrasounds of both lower limbs in this retrospective study. Univariate analysis and multivariate logistic regression analysis were conducted on factors with significant group differences to screen for the independent risk factors of MCVT. A nomogram to predict the risk of MCVT was constructed and validated with bootstrap resampling.

Results

According to the exclusion criteria, 240 patients were included for analysis, divided into the MCVT group (n = 81) and the non-MCVT group (n = 159). Multivariate logistic regression analyses showed that hypertension, elevated MPV, reduced albumin (ALB), elevated D-dimer and bed rest ≥3 days were independent risk factors for MCVT in AECOPD. A nomogram model for predicting AECOPD with MCVT was established based on them. The area under the curve (AUC) of receiver operating characteristic (ROC) curve for the prediction model and the simplified Wells score was 0.784 (95% CI: 0.722–0.847) and 0.659 (95% CI: 0.583–0.735), respectively. The cut-off value and Youden index of prediction model were 0.248 and 0.454, respectively. At the same time, the sensitivity, specificity, positive predictive value, and negative predictive value of the prediction model were 85.9%, 59.5%, 84.6%, and 77.4%, respectively. The sensitivity and specificity of the simplified Wells score were 67.9% and 56.3%, respectively. Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, and the decision analysis curve (DAC) suggested that this prediction model involved high clinical practicability.

Conclusion

We developed a nomogram that can predict the risk of MCVT for AECOPD patients. This model has the potential to assist clinicians in making treatment recommendations and formulating corresponding prevention measures.

Correlation of cardiac troponin T and APACHE III score with all-cause in-hospital mortality in critically ill patients with acute pulmonary embolism

Pulmonary embolism (PE) is a fatal condition particularly in critically ill patients. We determined the association among the cardiac troponin T (cTnT) level, acute physiologic and chronic health evaluation (APACHE III) scoring system, and in-hospital mortality in critically ill patients with acute PE. A total of 501 patients with PE were initially enrolled. According to the multivariable logistic regression model for in-hospital mortality, the odds ratio of the cTnT level and APACHE III score was 1.96 (95% confidence interval [CI] = 1.18–3.24, P = 0.008) and 1.03 (95% CI = 1.02–1.05, P < 0.001), respectively. The area under the curve (AUC) of cTnT and APACHE III score for in-hospital mortality was 0.630 (95% CI = 0.586–0.672, P = 0.03) and 0.740 (95% CI = 0.699–0.778, P = 0.02), respectively. The discriminatory cTnT and APACHE III threshold values for in-hospital mortality were 0.08 ng/L and 38 score, respectively; the sensitivities and specificities of cTnT were 46.48 and 83.10%, respectively, whereas those of the APACHE III score were 74.88 and 54.19%, respectively. The cTnT and APACHE III scores were combined in the logistic analysis model, and a regression equation was derived to calculate the in-hospital mortality. The AUC was found to increase to 0.788 (95% CI = 0.734–0.840, P = 0.025). The sensitivity and specificity increased to 84.5 and 71.4%, respectively. The cTnT and APACHE III scores exhibited a significant association with in-hospital mortality of critically ill patients with PE. In conclusion, these parameters in combination can significantly improve the in-hospital mortality prediction.

How Would You Treat This Patient With Pulmonary Embolism? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.

Ultra-Low-Dose Systemic Tissue Plasminogen Activator in High-Risk Submassive Pulmonary Embolism

Risk stratification of pulmonary embolism (PE) is vital for clinical management. While low-risk and high-risk PE management are clearly defined in many societal guidelines, the management of moderate-risk, also called submassive, PE remains unsettled. There is a subgroup of patients with submassive PE that progress to the severe category despite receiving systemic anticoagulation. The role of thrombolysis in the management of submassive PE remains to be established. We share our experience with ultra-low-dose (25-mg) systemic tissue plasminogen activator in a series of 4 patients with high-risk submassive PE.

Initial experience and early outcomes of the management of acute pulmonary embolism using the FlowTriever mechanical thrombectomy device

BACKGROUND

Submassive and massive pulmonary embolism is associated with a high risk of complications. We aimed to evaluate our initial experience with a mechanical thrombectomy device in the management of these patients.

METHODS

A single-center, retrospective study was performed in patients with acute submassive and massive pulmonary embolism treated with the FlowTriever device (Inari Medical, Irvine, CA, USA) between June 2019 and November 2020. Clinical and technical parameters were analyzed during the hospitalization and at 30- and 180-days after the procedure.

RESULTS

Fourteen patients were evaluated with a median (IQR) age of 60 (50-69) years and 64% were male. All had right heart strain as the main indication for thrombectomy. The procedure duration and fluoroscopic time was 52 (37-89) and 13 (9-24) minutes, respectively. There was 100% technical success, and the pulmonary arterial pressure went from 60 (48-65) mmHg to 40 (34-47) mmHg. Thrombolysis was used in two patients and nine patients required intensive care. 100% experienced improvement in symptoms at the time of discharge. There were no device-related complications, major bleeding events, myocardial infarctions, or deaths. Preprocedural hemoglobin was 13 (12-15) g/dL, and predischarge was 12 (10-13) g/dL. Overall postprocedural length of stay was three (2-6) days. All the patients were discharged with oral anticoagulation. There were no device-related complications or recurrence of embolism at 30 and 180 days.

CONCLUSIONS

The mechanical thrombectomy device for submassive and massive pulmonary embolism is promising and appears a safe and effective procedure with 100% technical success, no complications, short intensive care requirement/stay, and good early clinical outcomes.

Pulmonary Embolism in Transit Across a Patent Foramen Ovale

A pulmonary embolism (PE) is an obstruction in a pulmonary artery, and a saddle PE occurs when the obstruction is lodged in the main pulmonary trunk and spans the left and right pulmonary arteries. The current case study describes complications of a thrombus in transit across a patent foramen ovale (PFO). A 35-year-old female presented to the emergency department after a nontraumatic syncopal fall. She had recently returned from a cross-country flight 10 days before and had noticed left calf tenderness when exiting the plane. Vitals were notable for sinus tachycardia at 120 bpm. An electrocardiogram indicated an S1Q3T3 pattern, and chest computed tomographic angiography was positive for a saddle PE. A 2D (two-dimensional) transthoracic echocardiogram showed right ventricular free wall hypokinesis and McConnell’s sign. Echocardiogram findings were concomitant with a thrombus in transit across the interatrial septum, indicating a possible PFO. An emergency pulmonary embolectomy with cardiopulmonary bypass and closure of her PFO was performed the following morning and complicated by cardiogenic shock and subsequent cardiac arrest. The patient was resuscitated in the operating room but failed to be removed from cardiopulmonary bypass, requiring low-dose inotropic support and venoarterial extracorporeal membrane oxygenation flow at 4 L/min. After a repeat right pulmonary artery thrombectomy and two subsequent transesophageal echocardiograms indicated stable right ventricular systolic function, decannulation was performed. The patient was discharged on day 17 with long-term anticoagulation and home healthcare. In the current case report, the patient’s unstable and deteriorating condition was complicated by unusual findings of a thrombus in transit across a PFO. These additional echocardiogram findings represented an unusual case that warranted surgical treatment instead of systemic thrombolysis therapy because of the increased risk of systemic clot embolization.

Inpatient Management of Pulmonary Embolism: Clinical Characteristics and Mortality in a High-Volume Tertiary Care Center

The optimal management strategy for submassive or intermediate risk pulmonary embolism (IRPE)-anticoagulation alone versus anticoagulation plus advanced therapies-remains in equipoise leading many institutions to create multidisciplinary PE response teams (PERTs) to guide therapy. Cause-specific mortality of IRPE has not been thoroughly examined, which is a meaningful outcome when examining the effect of specific interventions for PE. In this retrospective study, we reviewed all adult inpatient admissions between 8/1/2018 and 8/1/2019 with an encounter diagnosis of PE to study all cause and PE cause specific mortality as the primary outcomes and bleeding complications from therapies as a secondary outcome. There were 429 total inpatient admissions, of which 59.7% were IRPE. The IRPE 30-day all-cause mortality was 8.7% and PE cause-specific mortality was 0.79%. Treatment consisted of anticoagulation alone in 93.4% of cases. Advanced therapies-systemic thrombolysis, catheter directed thrombolysis, or mechanical thrombectomy, were performed in only six IRPE cases (2.3%). Decompensation of IRPE cases requiring higher level of care and/or rescue advanced therapy occurred in only five cases (2%). In-hospital major bleeding and clinically relevant non-major bleeding were more common in those receiving systemic thrombolysis (61.5%) compared to anticoagulation combined with other advanced therapies (11.7%). Despite the high overall acuity of PE cases at our institution, in-hospital all-cause mortality was low and cause-specific mortality for IRPE was rare. These data suggest the need to target other clinically meaningful outcomes when examining advanced therapies for IRPE.

Percutaneous Mechanical Thrombectomy of Submassive Pulmonary Embolism and Extensive Deep Venous Thrombosis for Early Thrombus Removal

Traditional treatment with anticoagulation in nonfatal submassive pulmonary embolism can result in serious sequelae of chronic thromboembolic pulmonary hypertension or poor exercise tolerance, and functional impairment. To prevent long-term complications in previously healthy young patients, other treatment options to actively resolve existing thrombi should be considered. Despite recommendations for use in only severe clinical presentations, endovascular interventional techniques could serve as suitable treatment options for such patients. Here we report the case of a previously healthy 23-year-old female with submassive pulmonary embolism and extensive deep vein thrombosis in the inferior vena cava down to the right popliteal vein. The patient was initially treated with catheter-directed thrombolysis. However, she continued to show extensive venous thrombosis and pulmonary embolism. Percutaneous thrombectomy and aspiration using an AngioJet successfully removed the main pulmonary artery embolism and venous thrombus. The patient's recovery was uneventful, and 3-month follow-up showed no signs of recurrence or discomfort.

Predictors of residual pulmonary vascular obstruction after anticoagulation monotherapy in patients with intermediate-risk pulmonary embolism

Background

Patients with intermediate-risk pulmonary embolism (PE) can be treated with anticoagulation monotherapy. However, clinicians are concerned as to whether anticoagulation monotherapy is sufficient to reduce mortality in patients with a large embolic burden, and to resolve vascular obstruction. We investigated whether anticoagulation monotherapy was appropriate in patients with intermediate risk PE in terms of the occurrence of residual pulmonary vascular obstruction (RPVO), and the factors that independently predict the occurrence of RPVO.

Methods

This was a multicenter retrospective observational study of patients at intermediate risk of PE who were admitted to three hospitals between January 2012 and December 2017.

Results

Of total 91 patients, the median age was 72 years and 37 (40.7%) were male. Twenty-five patients (27.5%) were diagnosed with RPVO during follow-up. Multivariate logistic regression revealed chronic lung disease [odds ratio (OR), 4.14; 95% confidence interval (CI), 1.243–13.797; P=0.021] and the ratio of the diameters of the main pulmonary artery and ascending aorta ratio (P/A ratio) >1.0 documented on a chest computed tomography (CT) at presentation (OR, 3.46; 95% CI, 1.113–10.770; P=0.032) were significant independent predictors of RPVO occurrence. The incidence of RPVO in patients without these two factors was only 9.7%, but in those with the two factors it was 60% (P=0.004).

Conclusions

Anticoagulation monotherapy did not seem to be a sufficient treatment to reduce RPVO, but the outcome was similar to that of patients treated with other therapies. Therefore, considering the risk-benefit ratio, we do not need to change the initial treatment as systemic thrombolytic therapy or catheter-based therapy in patient with intermediate risk PE. Underlying chronic lung disease and a P/A ratio >1 on the initial chest CT predicted the occurrence of RPVO. Therefore, we should carefully assess persistent of dyspnea and exercise limitations using various methods in patients with these risk factors, to detect the occurrence of chronic thromboembolic pulmonary disease (CTEPD) earlier.

Resting heart rate as a surrogate for improvement in intermediate risk pulmonary embolus patients?

BACKGROUND

Pulmonary embolism (PE) response teams (PERT) have been developed to improve in-hospital mortality. Identifying intermediate risk PE patients that will progress despite anticoagulation is difficult, especially because outcomes with modern anticoagulation are quite good.

OBJECTIVE

The primary aim of this study was to evaluate the rate of anticoagulation failure (new deep vein thrombosis or PE, right ventricular failure resulting in shock, cardiac arrest, or PE-attributable death) in intermediate risk PE patients managed by PERT. The secondary objective was to determine whether there was a significant decrease in heart rate 24 h after initiation of anticoagulation in intermediate risk PE.

METHODS

This was a retrospective observational study of patients treated for acute intermediate risk PE at the University of Rochester Medical Center who also had outpatient followup between November 2016-June 2019.

RESULTS

Ninety-two patients presented as intermediate-risk PE and had outpatient followup. Seventy-four patients were initially treated with anticoagulation. None of these patients failed anticoagulation. Of the eighteen intermediate risk patients that underwent advanced intervention, none failed anticoagulation first. There was significant decrease in resting heart rate 24 h after starting therapeutic anticoagulation, 107 beats/min vs 89 beats/min, p = 0.0001.

CONCLUSION

We did not observe anticoagulation failure in the management of acute, intermediate risk PE. Reductions in heart rate may reflect improvements in right ventricular function; we hypothesize that those whose heart rate does not fall may be optimal candidates for advanced intervention.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

"Whole life changed" - Experiences of how symptoms derived from acute pulmonary embolism affects life. A qualitative interview study

INTRODUCTION

Acute pulmonary embolism (PE) presents itself with a wide range of hemodynamic consequences. Respiratory symptoms as dyspnea and respiratory pain are common. The aim of this study was to explore patients' experiences of how symptoms affected their physical and social activities following the PE.

MATERIALS AND METHODS

Qualitative interviews were conducted with 14 patients, with median time of 7 months (range 3-34 months) since the PE and analysed with qualitative content analysis according to Graneheim and Lundman.

RESULTS

The findings indicated that respiratory symptoms affected many aspects of life, illustrated by an overall theme: "Whole life changed". Two major categories, on changes of psychological/social nature, and changes of perception towards physical activity, described how the participants experienced changes in themselves and their relations, and that the psychological affection resulted in an existential crisis. All participants experienced changes in their physical activity and that remaining respiratory symptoms hindered them from being active. Fear inhibited physical activity and created a feeling of low self-efficacy concerning activity in general.

CONCLUSIONS

To the best of our knowledge, this is the first study to present results on experiences of how the symptoms deriving from PE affected the physical and social activities of the participants during recovery phase. The results indicate that patients with PE need support from the health care system to manage both psychological and physical symptoms in the aftermath of their illness. Further research is needed to find out how optimal rehabilitation for these patients should be designed.

Advanced therapies for pulmonary embolism

PURPOSE OF REVIEW

Treatment options for managing patients with acute pulmonary embolism are rapidly evolving. In this review, we discuss the supporting evidence and implementation strategies for these advanced therapeutic modalities.

RECENT FINDINGS

We review the recent data supporting systemic and catheter directed thrombolytic therapies, mechanical embolectomy, use of extracorporeal membrane oxygen support, and pulmonary embolism response teams in managing patients with acute pulmonary embolism. We discuss the major professional society recommendations regarding their implementation.

SUMMARY

A review of advanced therapies for pulmonary embolism.

Effects of the Sn100 kVp Tube Voltage Mode on the Radiation Dose and Image Quality of Dual-Source Computed Tomography Pulmonary Angiography

OBJECTIVE

This study aimed to investigate the effects of the Sn100 kVp tube voltage mode on the image quality and radiation dose of computed tomography pulmonary angiography (CTPA).

METHODS

A total of 145 patients who underwent CTPA were randomly divided into five groups: control group (120 kVp, 150 mAs), test group A (Sn100 kVp, 270 mAs), test group B (120 kVp, 30 mAs), test group C (70 kVp, 150 mAs), and test group D (80 kVp, 70 mAs). After image post-processing, the image quality and radiation dose of each group were analyzed.

RESULTS

The computed tomography values of images in the four test groups were more than 250 HU, which met the criteria for diagnosis. The signal-to-noise ratio and contrast-to-noise ratio of the images in the four test groups were lower than those in the control group. The radiation dose in each test group was lower than in the control group. The radiation dose was lowest in test group A.

CONCLUSION

The Sn100 kVp energy spectrum purification protocol can meet the requirements for clinical diagnosis, ensure image quality, and reduce the dose of radiation that patients receive.

Cost-effectiveness microsimulation of catheter-directed thrombolysis in submassive pulmonary embolism using a right ventricular function model

Approximately 30-50% of hemodynamically stable patients presenting with acute pulmonary embolism (PE) have evidence of right ventricular (RV) dysfunction. These patients are classified as submassive PE and the role of reperfusion therapy remains unclear. We sought to identify the circumstances under which catheter-directed thrombolysis (CDT) would represent high-value care for submassive PE. We used a computer-based, individual-level, state-transition model with one million simulated patients to perform a cost-effectiveness analysis comparing the treatment of submassive PE with CDT followed by anticoagulation to treatment with anticoagulation alone. Because RV function impacts prognosis and is commonly used in PE outcomes research, our model used RV dysfunction to differentiate health states. One-way, two-way, and probabilistic sensitivity analyses were used to quantify model uncertainty. Our base case analysis generated an incremental cost-effectiveness ratio (ICER) of $119,326 per quality adjusted life year. Sensitivity analyses resulted in ICERs consistent with high-value care when CDT conferred a reduction in the absolute probability of RV dysfunction of 3.5% or more. CDT yielded low-value ICERs if the absolute reduction was less than 1.56%. Our model suggests that catheter-directed thrombolytics represents high-value care compared to anticoagulation alone when CDT offers an absolute improvement in RV dysfunction of 3.5% or more, but there is substantial uncertainly around these results. We estimated the monetary value of clarifying the costs and consequences surrounding RV dysfunction after submassive PE to be approximately $268 million annually, suggesting further research in this area could be highly valuable.

Pulmonary Embolism: A Practical Guide for the Busy Clinician

Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.

ATS Core Curriculum 2020. Adult Pulmonary Medicine

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine in a 3- to 4-year recurring cycle of topics. The topics of the 2020 Pulmonary Core Curriculum include pulmonary vascular disease (submassive pulmonary embolism, chronic thromboembolic pulmonary hypertension, and pulmonary hypertension) and pulmonary infections (community-acquired pneumonia, pulmonary nontuberculous mycobacteria, opportunistic infections in immunocompromised hosts, and coronavirus disease [COVID-19]).

Inferior Vena Cava Filters: Past, Present, and Future

Inferior vena cava (IVC) filters have existed as a treatment option for VTE for decades. Advances in medical technology have provided physicians with several options for devices that can be placed on either a permanent or temporary basis; however, there are limited data from randomized, controlled trials on the appropriate use of IVC filters. This contemporary review summarizes the history of IVC filters and the types that are available in clinical practice. It reviews the literature on the use of IVC filters and discusses the indications that professional societies have endorsed for their use. In addition, it outlines the complications of IVC filter placement and future research directions.

Prothrombotic fibrin clot properties associated with NETs formation characterize acute pulmonary embolism patients with higher mortality risk

Venous thromboembolism is associated with formation of denser fibrin clots resistant to lysis. We investigated whether prothrombotic plasma clot properties are associated with the severity of acute pulmonary embolism (PE). We enrolled 126 normotensive acute PE patients (aged 58 ± 14 years) and 25 age- and sex-matched healthy controls. Plasma fibrin clot permeability (K_s), clot lysis time (CLT), endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1), and citrullinated histone H3 (citH3) were evaluated on admission. PE patients compared to controls had 370% higher citH3 levels, 41% higher ETP, 16.5% reduced K_s, and 25.6% prolonged CLT. Patients with intermediate-high (n = 29) and intermediate-low (n = 77) PE mortality risk had reduced K_s and prolonged CLT, increased PAI-1 and ETP as compared to low-risk PE (n = 20) patients. Prolonged CLT was predicted by PAI-1 and citH3, while low K_s by C-reactive protein. During a 12-month follow-up 9 (7.1%) patients who had 24% higher ETP, 45% higher citH3 levels, and 18% prolonged CLT at baseline died. High ETP combined with elevated citH3 levels and prolonged CLT was associated with eightfold increased risk of PE-related death. Prothrombotic fibrin clot properties and enhanced neutrophil extracellular traps formation are associated with higher early mortality risk in acute PE patients, which suggests a prognostic role of these biomarkers.

Right ventricular stroke distance predicts death and clinical deterioration in patients with pulmonary embolism

PURPOSE

The right ventricular outflow tract (RVOT) velocity time integral (VTI), an echocardiographic measure of stroke distance, correlates with cardiac index. We sought to determine the prognostic significance of low RVOT VTI on clinical outcomes among patients with acute pulmonary embolism (PE).

MATERIALS AND METHODS

We conducted a retrospective review of echocardiograms on Pulmonary Embolism Response Team (PERT) activations at our institution. The main outcome was a composite of death, cardiac arrest, or hemodynamic deterioration.

RESULTS

Of 188 patients, 30 met the combined outcome (16%) and had significantly lower RVOT VTI measurements (9.0 cm v 13.4 cm, p < 0.0001). The AUC for RVOT VTI at a cutoff of 10 cm was 0.78 (95% CI 0.67-0.90) with a sensitivity, specificity, negative predictive value, and positive predictive value of 0.72, 0.81, 0.94, and 0.42, respectively. Fifty-two patients of the cohort were classified as intermediate-high-risk PE and 21% of those met the combined outcome. RVOT VTI was lower among outcome positive patients (7.3 cm v 10.7 cm, p = 0.02).

CONCLUSIONS

Low RVOT VTI is associated with poor clinical outcomes among patients with acute PE.

Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism

BACKGROUND

Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established.

METHODS

To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data.

RESULTS

317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications.

CONCLUSIONS

At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.

Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.