Acute Symptomatic Pulmonary Embolism Research Articles

Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis

IntroductionWe recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. MethodsWe re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. ResultsWe studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41–57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091–0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4–12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35–1.8). ConclusionIn this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.

Correlation between short-term air pollution exposure and unprovoked lung embolism. Prospective observational (Contamina-TEP Group)

BackgroundThe aim was to analyze the temporal relationship between short-term air pollution exposure and acute symptomatic unprovoked pulmonary embolism (PE). Patients/methodsWe performed a prospective, multicenter study in consecutive patients diagnosed with acute symptomatic unprovoked PE from February 2012 to January 2013. We analyzed demographic and clinical data, patients' addresses, meteorological and air pollutants data (PM10, SO2, CO, NO2, ozone emission data). We considered the number of days the patient had symptoms, and the study period constituted the previous 30 days. Likewise, the mean annual data of the reference season were calculated as well as the data of the 30-day study period corresponding to the same dates in the previous 3 years in order to obtain the monthly mean of the different pollutants for each period. ResultsA total of 162 patients with acute symptomatic PE were recruited (43.2% unprovoked PE). The air pollutants could be determined in 50% of the patients with unprovoked PE, and a final analysis was performed in 35 patients. In the multiple comparison analysis to verify a possible correlation between the study period and the annual median, only NO2 showed a statistically significant association (p = 0.009). When comparing the study period with the previous 3 years, only NO2 maintained a statistically significant association for the 3 study periods. ConclusionsWe found a relationship between short-term exposure to NO2 and the presence of unprovoked PE.

Need for Transthoracic Echocardiogram in Patients with Low-Risk Pulmonary Thromboembolism: A Systematic Review and Meta-Analysis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram. MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I2 testing to assess heterogeneity. ResultsThe meta-analysis included a total of 11 studies with 1868 low-risk PE patients. Ten of the 447 (2.2%; 1.1%–4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1421 (0.7%; 0.3%–1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8–5.1, P=.14; I2=8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7–16, P<.01; I2=0%). ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

IntroductionCOVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. MethodsWe evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. ResultsWe studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. ConclusionThe 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.

Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review.

The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

P631 A misleading EKG and the saviour echo

Abstract Introduction Floating right heart thrombi (in transit from the legs to the pulmonary arteries) are a severe form of venous thromboembolism, with a high early mortality rate without treatment. Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism. Case Report Woman, 76 years old. Previous medical history of hypertension, dyslipidaemia, mitral valve repair and hypothyroidism. Recent admission in our cardiology department with de diagnosis of NSTEMI. She performed an echocardiogram that revealed only an enlarged left atrium, with no other changes. EKG only revealed inversion of T waves in V2-V4 with posterior normalization during hospital stay. She underwent to coronary angiography and right dominance without any coronary lesions was showed. The presence of a fistula, with a badly defined route, was also pointed in the coronary angio. One month after this episode she was admitted again in our emergency department due to onset of dyspnoea and productive cough. The physical examination showed SatO2: 90%; BP: 95/53 mmHg; HR: 100 bpm; Respiratory rate: 27 cpm; Apyretic (36,9ºC). Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. EKG revealed a sinus tachycardia, HR 122 bpm, with ST elevation in aVR and ST depression in DI, DII, aVL and V2-V6. Presence of S wave in DI and Q wave in DIII. While the EKG was being performed the patient presented a sudden cardiovascular deterioration (with blood pressure (BP: 67/35mmHg) drop and appearance of chest pain). We performed an arterial-blood gas test that revealed: pH7,16; pCO2 26,5; pO78,7; Potassium 4; Sodium 138; lactates 8,8. With these findings we decided to perform an echocardiogram to identify a possible cause for the shock. The echo showed right dilated chambers (with D-shape in parasternal short axis) with dilated IVC. We also point out the presence of a mobile intra-cardiac mass at the level of right atrium, suggestive of thrombus. We assumed the presence of obstructive shock in the context of pulmonary embolism. Thrombolysis was performed with clinical improvement of the patient. Medical therapy was optimized and heparin was initiated after the patient finished alteplase perfusion. During hospital stay the patients didn’t have any other cardiovascular complication and went home after 7 days in hospital. A venous doppler was performed before hospital discharge and it revealed the presence of a deep venous thrombosis at the level of right femoral vein. Conclusion The authors presented a didactic clinical case where the EKG mislead us to a possible Acute Coronary Syndrome involving the left main artery. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.

Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism.

Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.

Post-pulmonary embolism syndrome phenotyping with systematic multiparametric evaluation: A Prospective Study on 153 patients

Persistence of symptoms and discomfort after pulmonary embolism (PE) is frequent and poorly understood. To identify patients who remained symptomatic 6 months after an acute PE, and to determine factors associated with a 6-months functional impairment. One hundred and fifty-three patients with acute symptomatic PE were prospectively included from February 2015 to January 2017 at the University hospital of Toulouse, France. Clinical and paraclinical data were evaluated at inclusion and after 6 months of follow-up. Six-month follow-up included clinical evaluation, psychiatric survey, echocardiography and functional cardiopulmonary test. Symptomatic patients (i.e. patients with dyspnea and/or chest discomfort) underwent a ventilation-perfusion scintigraphy scan. Sixty (39%) patients remained symptomatic 6 months after the acute PE. After multivariate analysis, only an initial history of deep vein thrombosis (DVT) was predictive of 6-months symptoms (OR 3.35, 95% CI [1.19–9.39], P = 0.022), while initial use of low molecular weight heparin (LMWH) was protective (OR 0.36, 95% CI [0.13–0.96], P = 0.041). The six-month functional test appears to be related to symptoms. There was no difference in clinical, laboratory or echocardiographic parameters between symptomatic and asymptomatic patients. No pathological defect was found on ventilation-perfusion scintigraphy for 27 (52%) of symptomatic patients. Persistence of symptoms at six months of PE is frequent and is associated with a history of DVT and less frequent with initial LMWH therapy. Pathophysiology of post-pulmonary embolism syndrome is complex and not related to the initial PE severity nor the parameters of echocardiography.

P.161 Factors affecting the efficacy of adjunctive aripiprazole in risperidone- or paliperidone-induced hyperprolactinemia

The optimal cutoff for systolic blood pressure (SBP) level to define high-risk pulmonary embolism (PE) remains to be defined.To evaluate the relationship between SBP levels on admission and mortality in patients with acute symptomatic PE, the current study included 39,257 consecutive patients with acute symptomatic PE from the RIETE registry between 2001 and 2018. Primary outcomes included all-cause and PE-specific 30-day mortality. Secondary outcomes included major bleeding and recurrent venous thromboembolism (VTE).There was a linear inverse relationship between admission SBP and 30-day all-cause and PE-related mortality that persisted after multivariable adjustment. Patients in the lower SBP strata had higher rates of all-cause death (reference: SBP 110–129 mmHg) (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI], 2.0–4.2 for SBP <70 mmHg; and OR 1.7; 95% CI, 1.4–2.1 for SBP 70–89 mmHg). The findings for 30-day PE-related mortality were similar (adjusted OR 4.4; 95% CI, 2.7–7.2 for SBP <70 mmHg; and OR 2.6; 95% CI, 1.9–3.4 for SBP 70–89 mmHg). Patients in the higher strata of SBP had significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR 0.7; 95% CI, 0.5–0.9 for SBP 170–190 mmHg; and OR 0.6; 95% CI, 0.4–0.9 for SBP >190 mmHg). Consistent findings were also observed for 30-day PE-related death.In patients with acute symptomatic PE, a low SBP portends an increased risk of all-cause and PE-related mortality. The highest mortality was observed in patients with SBP <70 mmHg.

Necesidad de una ecocardiografía transtorácica en pacientes con tromboembolia de pulmón de riesgo bajo: revisión sistemática y metanálisis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram. MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I2 testing to assess heterogeneity. ResultsThe meta-analysis included a total of 11 studies 1,868 patients with low-risk PE. Ten of the 447 (2.2%; 1.1%-4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1,421 (0.7%; 0.3-1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8-5.1, p=.14; I2=8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7-16, p <.01; I2=0%). ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.

Systolic blood pressure and mortality in acute symptomatic pulmonary embolism

BackgroundThe optimal cutoff for systolic blood pressure (SBP) level to define high-risk pulmonary embolism (PE) remains to be defined. MethodsTo evaluate the relationship between SBP levels on admission and mortality in patients with acute symptomatic PE, the current study included 39,257 consecutive patients with acute symptomatic PE from the RIETE registry between 2001 and 2018. Primary outcomes included all-cause and PE-specific 30-day mortality. Secondary outcomes included major bleeding and recurrent venous thromboembolism (VTE). ResultsThere was a linear inverse relationship between admission SBP and 30-day all-cause and PE-related mortality that persisted after multivariable adjustment. Patients in the lower SBP strata had higher rates of all-cause death (reference: SBP 110–129 mmHg) (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI], 2.0–4.2 for SBP <70 mmHg; and OR 1.7; 95% CI, 1.4–2.1 for SBP 70–89 mmHg). The findings for 30-day PE-related mortality were similar (adjusted OR 4.4; 95% CI, 2.7–7.2 for SBP <70 mmHg; and OR 2.6; 95% CI, 1.9–3.4 for SBP 70–89 mmHg). Patients in the higher strata of SBP had significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR 0.7; 95% CI, 0.5–0.9 for SBP 170–190 mmHg; and OR 0.6; 95% CI, 0.4–0.9 for SBP >190 mmHg). Consistent findings were also observed for 30-day PE-related death. ConclusionsIn patients with acute symptomatic PE, a low SBP portends an increased risk of all-cause and PE-related mortality. The highest mortality was observed in patients with SBP <70 mmHg.

P9. Abstract Title: Systolic Blood Pressure and Mortality in Acute Symptomatic Pulmonary Embolism

<h3>Importance</h3> The optimal cut-off for systolic blood pressure (SBP) to define high-risk pulmonary embolism (PE) remains to be defined. <h3>Objectives</h3> To evaluate the relationship between SBP on admission and short-term mortality and other cardiovascular events in patients with acute symptomatic PE. <h3>Design, Setting and Participants</h3> The Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) Registry is an ongoing, multi-center, international, prospective registry of consecutive patients with symptomatic, objectively confirmed, acute venous thromboembolism (VTE). The current study included 39,257 patients from RIETE with acute symptomatic PE between 2001 and 2018. <h3>Main Outcomes and Measures</h3> Primary outcomes included all-cause and PE-specific 30-day mortality. Secondary outcomes included major bleeding and recurrent venous thromboembolism (VTE). <h3>Results</h3> There was a linear inverse relationship between admission SBP and 30-day all-cause and PE-related mortality that persisted after multivariable adjustment. Patients in the lower SBP strata had higher rates of all-cause death (reference: SBP 120-129 mmHg) (adjusted odds ratio [OR] 2.9, 95% confidence interval [CI] 2.0-4.2 for SBP <70 mmHg, and OR 1.7, 95% CI 1.4-2.1 for SBP 70-89 mmHg). The findings for 30-day PE-related mortality were similar (adjusted OR 4.4, 95% CI 2.7-7.2 for SBP <70 mmHg, and OR 2.6, 95% CI 1.9-3.4 for SBP 70-89 mmHg). After adjustment for all covariates, we did not find a significant relationship between admission SBP and recurrence or bleeding. <h3>Conclusions</h3> In patients with acute symptomatic PE, a low SBP portends an increased risk of all-cause and PE-related mortality. The highest mortality was observed in patients with SBP <70 mmHg.

P5017Factors associated with a negative D-dimer test in patients diagnosed with acute symptomatic pulmonary embolism

Abstract Background The recommended diagnostic strategy for suspected acute pulmonary embolism (PE) combines the assessment of pre-test probability, D-dimer level, and -if indicated- computed tomography pulmonary angiography. Purpose To evaluate the frequency and potential explanations for negative D-dimer tests in patients diagnosed with acute PE. Methods The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. The items of the Simplified revised Geneva Score and the D-dimer levels at diagnosis have been prospectively collected, but they did not necessarily guide management decisions. Quantitative D-dimer was measured on admission either by quantitative latex-based assays or enzyme-linked immunosorbent assays. A negative D-dimer was defined by fixed (0.50 μg/mL) or age-adjusted (age*0.01 μg/mL if age&gt;50) cut-off. Results Using the fixed cut-off, a negative D-Dimer was detected in 17 of 773 patients with ultimately diagnosed PE (miss rate 2.2% [95% CI 1.4–3.5]); using the age-adjusted cut-off, the test was discordant with the PE diagnosis in 24 patients (3.1% [2.1–4.6]). In Figure 1, red dots indicate negative D-dimer test by fixed cut-off and blue dots indicate additional negative D-dimer tests by age-adjusted cut-off. In 448 (59%) patients post-hoc classified as PE-unlikely, 11 (2.5% [1.4–4.3]) and 14 (3.1% [1.9–5.2]) patients had a negative D-dimer using the two different cut-offs, respectively. Haemoptysis on admission, V/Q scan-based diagnosis, and chronic lung disease were associated with a discordant D-dimer, while an inverse association existed for concomitant DVT. In 7 (29%) PE cases with normal D-dimer, PE was verified to be subsegmental also in a post-hoc evaluation. Another seven (29%) patients were receiving anticoagulation at the time of D-dimer assessment. Figure 1 Conclusions Our results show that the frequency of discordance between a normal D-dimer test and the diagnosis of acute PE is low, but not negligible. One third of discordant findings were related to subsegmental PE. Physicians should be aware that the risk of obtaining a false-negative D-dimer might be higher in specific subgroups of patients. Acknowledgement/Funding The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG

ACUTE PULMONARY EMBOLISM ASSOCIATED WITH A MOBILE RIGHT ATRIAL THROMBUS MANAGED BY SUCTION THROMBECTOMY

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/22/2019 3:45 PM - 4:45 PM INTRODUCTION: Pulmonary embolism (PE) associated with a free-floating right heart thrombus (RHT) carries a much higher mortality risk. Optimal management of RHT is controversial. Suction thrombectomy can be a viable treatment option. CASE PRESENTATION: A 66-year-old female was admitted for Rasmussen’s encephalitis. After 2 weeks in the hospital she developed sudden decreased motor skills, facial droop and lethargy. Computed tomography (CT) of the head and neck was unremarkable except for incidental large pulmonary emboli. CT angiogram of the chest confirmed PE extending from the distal main arteries into the lobar branches bilaterally (Fig. 1). An echocardiogram showed a 4x2.6 cm mobile mass within the right atrium that crossed the tricuspid valve (Fig. 2). She had been on deep vein thrombosis (DVT) prophylaxis throughout her hospital stay with subcutaneous heparin and over the 24-hour period preceding these events, her platelet count had decreased from 345,000 to 83,000. Argatroban infusion was started for suspected heparin induced thrombocytopenia. Venous doppler ultrasound showed a DVT in the left leg. She was hemodynamically stable with oxygen saturation in the upper 90’s on room air. However, the patient was considered to have a high mortality risk given her clot burden and the size of the mobile RHT. She was not a candidate for surgery or thrombolytics but considered a candidate for suction thrombectomy. During the procedure, intracardiac echocardiography identified a large thrombus completely filling the right atrium (Fig 3). The Penumbra® suction system was introduced via a 8.5 French sheath to perform the aspiration. Given the size of the thrombus, a snare was used to break up the clot while applying continuous suction with the penumbra device. Aspiration of the clot was successful with minimal residual clot present on the eustachian valve (Fig 4). Video images of the procedure were recorded. The patient did well after the procedure and was discharged on oral anticoagulation. DISCUSSION: There are several suction thrombectomy systems available. The smaller cannulas of the Penumbra® system provide the advantage of flexibility. To our knowledge, this is the first reported case using this system for the management of a RHT. The use of this device in intermediate-risk PE is currently being evaluated in a clinical trial. CONCLUSIONS: Given the lack of clear guidelines for management of RHT, suction thrombectomy with the Penumbra® system can be considered especially when thrombolytics are contraindicated. Further studies are however needed to assess its use for this indication. Reference #1: Barrios D, Rosa-Salazar V, Morillo R, Nieto R, Fernandez S, Zamorano JL, et al. Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis. Chest. 2017;151(2):409-16. Reference #2: Nosher JL, Patel A, Jagpal S, Gribbin C, Gendel V. Endovascular treatment of pulmonary embolism: Selective review of available techniques. World journal of radiology. 2017;9(12):426-37. Reference #3: Evaluating the Safety and Efficacy of the Indigo Aspiration System in Acute Pulmonary Embolism (EXTRACT-PE) [Available from: https://clinicaltrials.gov/ct2/show/NCT03218566 DISCLOSURES: No relevant relationships by Yasir Akhtar, source=Web Response No relevant relationships by Isaac Biney, source=Web Response No relevant relationships by Peter McKeown, source=Admin input No relevant relationships by Francisco Soto, source=Web Response No relevant relationships by J Turner, source=Web Response

P2772The rule-out criteria for chronic thromboembolic pulmonary hypertension can identify patients without haemodynamic abnormalities and functional limitation 3 and 12 months after acute PE

Abstract Background Up to one-third of patients report persisting hemodynamic abnormalities and functional limitation over long-term follow-up after acute pulmonary embolism (PE). Purpose We tested whether a validated algorithm designed to rule-out chronic thromboembolic pulmonary hypertension (CTEPH) after acute PE can be used for identifying patients at lower risk of presenting with persisting symptoms and echocardiographic abnormalities. Methods The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. We focused on the scheduled visits for 3- and 12-month follow-up. The rule-out criteria are based on: the absence of ECG signs of right ventricular dysfunction and normal NT-proBNP/BNP values. Echocardiographic abnormalities were defined according to the presence of abnormal parameters indicating an intermediate/high probability of pulmonary hypertension as recommended by the 2015 ESC/ERS Society Guidelines on Pulmonary Hypertension. The presence of functional limitation was defined based on a World Health Organization classification grade ≥3, a Borg dyspnoea index ≥4, or a 6-minute walking distance &lt;300 m. Results We included 323 patients (mean age 61 years, 58% men), of whom 255 have meanwhile completed a one-year follow-up. At 3- and 12-month follow-up, 194 (60%) and 155 (61%) of patients exhibited no abnormal echocardiographic findings or natriuretic peptide levels. The percentage of patients with echocardiographic abnormalities was 20.4% and 18.0%, respectively. The negative predictive value of the score for ruling out the combination of functional limitation and intermediate/high probability of pulmonary hypertension as recommended by the 2015 ESC/ERS Guidelines on Pulmonary Hypertension was 0.96 (95% CI 0.92–0.98) at 3 and 0.97 (0.92–0.99) at 12 months. The corresponding positive predictive values were 0.10 (0.06–0.17) and 0.09 (0.05–0.17), respectively. Conclusions The CTEPH rule-out criteria are capable of excluding functional limitation and evidence of (chronic) pulmonary hypertension 3 and 12 months after the diagnosis of acute PE. Acknowledgement/Funding The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG

Intermediate-High Risk Pulmonary Embolism.

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

Incidence of residual perfusion defects by lung scintigraphy in patients treated with rivaroxaban compared with warfarin for acute pulmonary embolism

Residual perfusion defects (RPD) as detected by lung scintigraphy occur in over 50% of patients with acute pulmonary embolism (PE) treated with vitamin K antagonists but there is lack of data in patients treated with direct oral anticoagulants. The aim of this retrospective study was to estimate the incidence of RPD detected by ventilation perfusion (VQ) scan at 3-6 months in patients with first acute symptomatic PE treated with rivaroxaban compared to warfarin. Consecutive eligible patients treated with rivaroxaban as part of a previous study were identified. The Monash Health Radiology database was used to identify a historical cohort of age matched (± 5 years) patients treated with warfarin. Follow-up VQ scans were classified as normal (no perfusion defect) or abnormal (matched or unmatched perfusion defects) by two independent nuclear medicine physicians blinded to treatment. Any disagreement was resolved by consensus. One hundred and ninety patients with PE (95 in each cohort) were included (mean age 56.8 years; 41.1% males; 54.2% unprovoked). In the overall cohort, 31.1% had RPD with a significantly lower incidence of RPD in rivaroxaban treated patients 23.2% (95% CI 15.8-32.6), compared to warfarin 38.9% (95% CI 29.8-49.0). Treatment with rivaroxaban was associated with a significantly lower incidence of RPD detected by VQ scan at 3-6 months compared to warfarin. This supports recent in-vitro data suggesting an indirect enhancement of fibrinolysis by direct oral Xa inhibitors but requires confirmation in larger studies.

Hospital volume and outcomes for acute pulmonary embolism: multinational population based cohort study

ObjectivesTo evaluate the association between experience in the management of acute pulmonary embolism, reflected by hospital case volume, and mortality.DesignMultinational population based cohort study using data from the Registro Informatizado...

Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study.

Pulmonary embolism (PE) is associated with increased risk for ischemic stroke, but the underlying mechanism remains unclear. The authors hypothesized that paradoxical embolism through patent foramen ovale (PFO) should be the main mechanism. To determine the frequency of recent ischemic stroke in patients with symptomatic PE according to whether PFO was detected. Prospective cohort study with masked assessment of stroke outcomes. (ClinicalTrials.gov: NCT01216423). 4 French hospital centers. 361 consecutive patients with symptomatic acute PE from 13 November 2009 through 21 December 2015. Systematic contrast transthoracic echocardiography (TTE) and cerebral magnetic resonance imaging (MRI) within 7 days after enrollment. Recent symptomatic or silent ischemic stroke was diagnosed on the basis of clinical examination and cerebral MRI showing a hypersignal on the trace diffusion-weighted image with reduction or pseudonormalization of apparent diffusion coefficient. Contrast TTE was conclusive in 324 of 361 patients and showed PFO in 43 patients (13%). The median age was 66 years (interquartile range, 54 to 77 years). In total, 51% of patients (145/284) had associated deep venous thrombosis, 91% (279/306) had cardiovascular risk factors, and 10% (16/151) presented with arrhythmia (no difference between PFO and non-PFO groups). Cerebral MRI was conclusive in 315 patients. Recent ischemic stroke was more frequent in the PFO group than in the non-PFO group (9 of 42 patients [21.4%] vs. 15 of 273 patients [5.5%]; difference in proportions, 15.9 percentage points [95% CI, 4.7 to 30.7 percentage points]). Because of inconclusive contrast TTE or MRI, 46 patients were excluded from analysis. Frequency of recent ischemic stroke in patients with symptomatic PE was higher in patients with PFO than in those without PFO. This finding supports the hypothesis that paradoxical embolism is an important mechanism of ischemic stroke in patients with PFO. French Ministry of Health.

Health-related quality of life and mortality in patients with pulmonary embolism: a prospective cohort study in seven European countries

PurposeLittle is known about the quality of life following pulmonary embolism (PE). The aim of the study was to assess the 12-month illness burden in terms of health-related quality of life (HrQoL) and mortality, in relation to differences in patient characteristics.MethodsThe PREFER in VTE registry, a prospective, observational study conducted in seven European countries, was used. Within 2 weeks following an acute symptomatic PE, patients were recruited and followed up for 12 months. Associations between patient characteristics and HrQoL (EQ-5D-5L) and mortality were examined using a regression approach.ResultsAmong 1399 PE patients, the EQ-5D-5L index score at baseline was 0.712 (SD 0.265), which among survivors gradually improved to 0.835 (0.212) at 12 months. For those patients with and without active cancer, the average index score at baseline was 0.658 (0.275) and 0.717 (0.264), respectively. Age and previous stroke were significant factors for predicting index scores in those with/without active cancer. Bleeding events but not recurrences had a noticeable impact on the HrQoL of patients without active cancer. The 12-month mortality rate post-acute period was 8.1%, ranging from 1.4% in Germany, Switzerland, and Austria to 16.8% in Italy. Mortality differed between patients with active cancer and those without (42.7% vs. 4.7%).ConclusionPE is associated with a substantial decrease in HrQoL at baseline which normalizes following treatment. PE is associated with a high mortality rate especially in patients with cancer, with significant country variation. Bleeding events, in particular, impact the burden of PE.