Parameters Of Right Ventricular Dysfunction Research Articles

Validation of American Society of Echocardiography Guideline-Recommended Parameters of Right Ventricular Dysfunction Using Artificial Intelligence Compared With Cardiac Magnetic Resonance Imaging

Right ventricular function is important in evaluation of cardiac function but its assessment by standard transthoracic echocardiographic (TTE) remains challenging. Cardiac magnetic resonance imaging (CMR) is considered the gold standard. The American Society of Echocardiography recommends surrogate measures of RV function and ejection fraction (RVEF) by TTE including fractional area change (FAC), free wall strain (FWS), and tricuspid annular planar systolic excursion (TAPSE), but they require technical expertise in acquisition and quantification. We sought to evaluate the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of FAC, FWS, and TAPSE derived by a rapid, novel artificial intelligence (AI) software (LVivoRV®) from a single-plane TTE apical 4-chamber (A4C), RV-focused view without ultrasound-enhancing agents for detecting abnormal RV function compared with CMR-derived RVEF. RV dysfunction was defined as RVEF<50% and <40% on CMR. TTE and CMR were performed within a median of 10 days [IQR: 2-32] of each other in 225 consecutive patients without interval procedural or pharmacological intervention. The sensitivity and NPV to detect CMR-defined RV dysfunction when all three AI-derived parameters (FAC, FWS, and TAPSE) were abnormal were 91% and 96%, while those of expert physician-reads were 91% and 97%. Specificities and PPV were lower (50% and 32%) compared with expert physician-read echocardiograms (82% and 56%). AI-derived measurements of FAC, FWS, and TAPSE had excellent sensitivity and NPV for ruling out significant RV dysfunction (CMR RVEF <40%), comparable to that of expert physician readers, but lower specificity. This AI, using ASE guidelines, may serve as a useful screening tool for rapid bedside assessment to exclude significant RV dysfunction.

Pulmonary artery diameter correlates with echocardiographic parameters of right ventricular dysfunction in patients with acute pulmonary embolism.

Right ventricular dysfunction (RVD) is a key component in the process of risk stratification in patients with acute pulmonary embolism (PE). Echocardiography remains the gold standard for RVD assessment, however, measures of RVD may be seen on CTPA imaging, including increased pulmonary artery diameter (PAD). The aim of our study was to evaluate the association between PAD and echocardiographic parameters of RVD in patients with acute PE. Retrospective analysis of patients diagnosed with acute PE was conducted at large academic center with an established pulmonary embolism response team (PERT). Patients with available clinical, imaging, and echocardiographic data were included. PAD was compared to echocardiographic markers of RVD. Statistical analysis was performed using the Student's t test, Chi-square test, or one-way analysis of variance (ANOVA); P < 0.05 was considered statistically significant. 270 patients with acute PE were identified. Patients with a PAD >30 mm measured on CTPA had higher rates of RV dilation (73.1% vs 48.7%, P < 0.005), RV systolic dysfunction (65.4% vs 43.7%, P < 0.005), and RVSP >30 mmHg (90.2% vs 68%, P = 0.004), but not TAPSE ≤1.6 cm (39.1% vs 26.1%, P = 0.086). A weak increasing linear relationship between PAD and RVSP was noted (r = 0.379, P = 0.001). Increased PAD in patients with acute PE was significantly associated with echocardiographic markers of RVD. Increased PAD on CTPA in acute PE can serve as a rapid prognostic tool and assist with PE risk stratification at the time of diagnosis, allowing rapid mobilization of a PERT team and appropriate resource utilization.

Association between right ventricular dysfunction and in-hospital mortality in surges of SARS-CoV-2 infection attributed to the Alpha, Delta, and Omicron variants.

Right ventricular (RV) dysfunction in acute COVID-19 was reported to be associated with poor prognosis. We studied the association between parameters of RV dysfunction and in-hospital mortality during the surges caused by different SARS-CoV-2 variants. In a retrospective single-center study, we enrolled 648 consecutive patients hospitalized with COVID-19 [66 (10%) hospitalized during the alpha variant surge, 433 (67%) during the delta variant surge, and 149 (23%), during the omicron variant surge]. Patients were reported from a hospital with an underreported population of mostly African American and Hispanic patients. Patients were followed for a median of 11days during which in-hospital death occurred in 155 (24%) patients [Alpha wave: 25 (38%), Delta Wave: 112 (26%), Omicron wave: 18 (12%), p<0.001]. RV dysfunction occurred in 210 patients (alpha: 32%, 26%, delta: 29%, and omicron: 49%, p<0.001) and was associated with higher mortality across waves, however, independently predicted in-hospital mortality in the Alpha (HR=5.1, 95% CI: 2.06-12.5) and Delta surges (HR=1.6, 95% CI: 1.11-2.44), but not in the Omicron surge. When only patients with RV dysfunction were compared, the mortality risk was found to decrease significantly from the Alpha (HR=13.6, 95% CI: 3.31-56.3) to the delta (HR=1.93, 95% CI: 1.25-2.96) and to the Omicron waves (HR=11, 95% CI: 0.6-20.8). RV dysfunction continues to occur in all strains of the SARS-CoV-2 virus, however, the mortality risk decreased from wave to wave likely due to evolution of better therapeutics, increase rate of vaccination, or viral mutations resulting in decrease virulence.Registration number of clinical studies: BronxCare Hospital center institutional review board under the number 05 13 21 04.

Abstract 10066: Right Ventricular Function as a Predictor of Mortality in Patients with Sepsis: A Systematic Review and Meta-Analysis

Introduction: Sepsis-associated myocardial dysfunction has been described in relation to left ventricular function and reported to have a variable correlation with mortality. However, the extent to which right ventricular (RV) dysfunction contributes to myocardial dysfunction and a poor prognosis in sepsis remains unknown. Our aim is to investigate the association between RV dysfunction and mortality in patients with sepsis. Methods: We performed a systematic review of the literature. We systematically searched Cochrane, Embase, MEDLINE, Scopus and Web of Science for full-text articles from inception to June 2020. Studies were included if they reported RV function and mortality in patients with sepsis using echocardiography. Data was extracted using a collection form designed a priori . Significance was determined by a two-tailed p value &lt; 0.05. The present study was registered in the PROSPERO (CRD42020204423). Hypothesis: RV dysfunction is associated to mortality in adult patients with sepsis. Results: Six studies including 526 patients were selected for final analysis. Patients had a mean age of 57 years, 45% were females, and there was an overall mortality of 37%. In three studies, transthoracic echocardiography was performed within 24h of sepsis diagnosis, and reported Tricuspid annular plane systolic excursion (TAPSE) in a total of 366 patients. In pooled analysis, survivors had a higher TAPSE compared to non-survivors ((SMD):1.89 (95%CI 0.14-3.655) p=0.03, Figure1). All other parameters of RV dysfunction assessed did not have a statistically significant difference between survivors and non-survivors (Figure 2-6). Conclusion: RV dysfunction as demonstrated by a lower TAPSE is associated with higher mortality in patients with sepsis and/or septic shock. This data suggest that RV dysfunction is an important contributor to sepsis-associated myocardial dysfunction and worsening prognosis in patients with sepsis.

Safety and efficacy of percutaneous catheter-directed treatment for intermediate-high risk pulmonary embolism

Abstract Background Pulmonary embolism (PE) is globally the third most frequent acute cardiovascular syndrome, ranking high among the causes of cardiovascular mortality. Systemic thrombolytic therapy (STT) permits prompt reperfusion after pulmonary obstruction, nevertheless this treatment carries by itself an inherent risk of major bleeding events. Development of new therapies and interventions that allow us to achieve early lung reperfusion along with a reduced risk of bleeding are necessary. Purpose The aim of this study was to evaluate the safety and efficacy of percutaneous catheter-directed treatment (PCDT) on intermediate-high risk PE patients with high bleeding risk or contraindication for STT. Methods We consecutively included all patients with intermediate-high risk PE undergoing PCDT in two university hospitals. Clinical, echocardiographic and hemodynamic variables (pre and post PCDT) were collected, as well as major adverse cardiac and bleeding events during follow-up. Results Between February 2018 and January 2021, we included 30 consecutive patients admitted with intermediate-high risk PE who underwent PCDT. Median age was 60 years, interquartile range (IQR) 51–72, and 41% were women. 14 patients (46.6%) presented an absolute contraindication for STT, which was the main reason for performing PCDT. Catheter-directed local thrombolysis (CDLT) was performed in 27 (90%) patients and mechanical fragmentation-aspiration was performed in 12 (40%) of them. We observed a significant reduction in mean pulmonary artery pressure (mPAP, mmHg) after PCDT: 40±13 vs. 25±12, p&amp;lt;0.001; as well as in NT-proBNP concentrations (pg/ml) 48 hours post-PCDT: 4791±1077 vs. 2311±680, p=0.002, (Figure 1). Echocardiographic parameters of right ventricular (RV) dysfunction also experienced a significant improvement 72 hours post-PCDT: TAPSE (mm) 15±2 vs. 22±3, p=0.001, (Figure 2); basal RV diameter (mm) 51±4 vs. 41±2, p=0.001. During a median follow-up of 13 months, IQR (8–22), 1 patient died from non-cardiac cause and no patient presented a bleeding event. Conclusions PCDT for intermediate-high risk PE is safe and effective, producing an early reduction in mPAP, in prognostic biomarkers such as NT-proBNP, as well as an early improvement of classic echocardiographic parameters of RV dysfunction. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Usefulness of Immunoglobulin A in Patients With Decompensated Heart Failure: Is It a Future Marker of Congestion? Preliminary Experience

The purpose of this study was to analyze whether the level of IgA is related to right ventricular function and systemic congestion in patients with decompensated heart failure (HF) and reduced ejection fraction (EF). This was a consecutive prospective and observational study of hospitalized patients diagnosed with decompensated HF with reduced EF. The recruitment period lasted 2 months. In the first 24 hours after admission, clinical assessment, general laboratory tests, determination of HF biomarkers, IgA and echocardiographic study were performed. Patients were classified into 2 groups according to whether the plasma IgA level was lower (n=11) or higher than 300 mg/dL (n=12). Significant differences in IgA levels were found in the peripheral congestion variables (no congestion: 232, interquartile range [IQR], 125-310 mg/dL vs congestion: 429, IQR, 308-520 mg/dL; P=.03). There were also differences in echocardiographic parameters of right ventricular function, with a greater deterioration of right ventricular function in the group with higher IgA levels (P < .05). There was a highly significant correlation between tricuspid annulus systolic excursion values and IgA levels (P=.004). In decompensated HF, patients with greater clinical congestion and echocardiographic parameters of right ventricular dysfunction have higher plasma IgA levels. This study is a preliminary experience that will help to establish the basis of the cardiointestinal syndrome as a clinical picture of systemic congestion in HF.

Right Ventricular Functional Abnormalities in Arrhythmogenic Cardiomyopathy: Association With Life-Threatening Ventricular Arrhythmias

ObjectivesThis study aimed to perform an external validation of the value of right ventricular (RV) deformation patterns and RV mechanical dispersion in patients with arrhythmogenic cardiomyopathy (AC). Secondly, this study assessed the association of these parameters with life-threatening ventricular arrhythmia (VA). BackgroundSubtle RV dysfunction assessed by echocardiographic deformation imaging is valuable in AC diagnosis and risk prediction. Two different methods have emerged, the RV deformation pattern recognition and RV mechanical dispersion, but these have neither been externally validated nor compared. MethodsWe analyzed AC probands and mutation-positive family members, matched from 2 large European referral centers. We performed speckle tracking echocardiography, whereby we classified the subtricuspid deformation patterns from normal to abnormal and assessed RV mechanical dispersion from 6 segments. We defined VA as sustained ventricular tachycardia, appropriate implantable cardioverter-defibrillator therapy, or aborted cardiac arrest. ResultsWe included 160 subjects, 80 from each center (43% proband, 55% women, age 41 ± 17 years). VA had occurred in 47 (29%) subjects. In both cohorts, patients with a history of VA showed abnormal deformation patterns (96% and 100%) and had greater RV mechanical dispersion (53 ± 30 ms vs. 30 ± 21 ms; p < 0.001 for the total cohort). Both parameters were independently associated to VA (adjusted odds ratio: 2.71 [95% confidence interval: 1.47 to 5.00] per class step-up, and 1.26 [95% confidence interval: 1.07 to 1.49]/10 ms, respectively). The association with VA significantly improved when adding RV mechanical dispersion to pattern recognition (net reclassification improvement 0.42; p = 0.02 and integrated diagnostic improvement 0.06; p = 0.01). ConclusionsWe externally validated 2 RV dysfunction parameters in AC. Adding RV mechanical dispersion to RV deformation patterns significantly improved the association with life-threatening VA, indicating incremental value.

Importance of computed tomography pulmonary angiography for predict 30-day mortality in acute pulmonary embolism patients

ObjectiveThe purpose of the present study was to assess the implications of different parameters of computed tomography pulmonary angiography (CTPA) to predict 30-day mortality in acute pulmonary embolism (APE) patients. Material and MethodPatients who had clinical suspicion of APE and underwent CTPA were recruited in a retrospective cohort study. The findings of the CTPA included the parameters of right ventricular dysfunction (RVD), the severity of obstruction to the pulmonary artery by CT obstruction index, and the ratio of pulmonary trunk diameter and aorta. The endpoint of the study was established as the 30-day mortality associated with APE. ResultsA total of 238 patients with a confirmed APE diagnosis with CTPA were included in the study; 26 (10.9 %) of those patients died within 30 days. In patients with cancer and the Pulmonary Embolism Severity Index (PESI) class 5, the mortality rate was significantly higher. Compared with survivors, the mean CT obstruction index in the non-survivor group was significantly higher (p < 0.001). Higher mortality was associated with all RVD parameters identified by CTPA, such as the RV/LV ratio (p < 0.001), interventricular septum deviation grade 3 (p < 0.001), increased RV diameter (p < 0.001), and IVC contrast reflux (p < 0.001). The highest adjusted odds ratio was RV diameter at 1.094, followed by PESI and the CT obstruction index at 1.040. ConclusionCTPA-detected RVD parameters and CT obstruction index can predict a 30-day mortality rate in APE patients and be used for risk stratification. In APE patients, the RV diameter of 53 mm or greater and the CT obstruction index >70% is associated with increased 30-day mortality.

Defining right ventricular dysfunction by echocardiography in normotensive patients with pulmonary embolism.

Although the prognostic value of various echocardiographic parameters of right ventricular dysfunction (RVD) was reported in normotensive patients with acute pulmonary embolism (PE), there is no generally accepted definition of RVD. The aim of the study was to compare echocardiographic parameters for the prediction of an adverse 30‑day outcome and create an optimal definition of RVD. Patients and methods: Echocardiographic parameters including the right ventricular to left ventricular diameter ratio (RV to LV ratio) and tricuspid annular plane systolic excursion (TAPSE) to predict PE‑related mortality, hemodynamic collapse, or rescue thrombolysis within the first 30 days were directly compared in 490 normotensive patients with PE. An adverse outcome (AO) was present in 31 patients (6.3%); 8 of them (1.6%) died due to PE. Systolic blood pressure, RV to LV ratio, and TAPSE were independent predictors of AO. The receiver operator characteristic yielded an area under the curve of 0.737 (0.654-0.819; P <0.001) for the RV to LV ratio and 0.75 (0.672-0.828; P <0.001) for TAPSE with regard to an AO. The hazard ratio for AO was 2.5 for the RV to LV ratio of more than 1 (95% CI, 1.2-5.7; P <0.03) and 3.8 for TAPSE of less than 16 mm (95% CI, 1.74-8.11; P = 0.001). A combined RVD criterion (TAPSE <16 mm and RV to LV ratio >1) was present in 60 patients (12%), and showed a positive predictive value of 23.3% with a high negative predictive value of 95.6% regarding an AO (HR, 6.5; 95% CI, 3.2-13.3; P <0.001). Defining RVD on echocardiography by the RV to LV ratio of more than 1 combined with TAPSE of less than 16 mm identified patients with an increased risk of 30‑day PE‑related mortality, hemodynamic collapse, or rescue thrombolysis, while patients without this sign had a very good 30‑day prognosis.

P4369Direct comparison of prognostic value of echocardiographic parameters of right ventricular dysfunction in normotensive patients with acute pulmonary embolism

Abstract Background Although various echocardiographic parameters of right ventricular dysfunction (RVD) were reported to be of prognostic value in normotensive patients with acute pulmonary embolism (APE), an optimal definition of RVD on echocardiography is missing. Purpose We performed a direct comparison of prognostic value of RV/LV ratio, TAPSE, and TRPG/TAPSE for complicated clinical course that included: in-hospital APE related mortality, hemodynamic collapse or rescue thrombolysis. Methods Prospective cohorts of APE patients normotensive at admission, managed according to the ESC Guidelines 2014 were merged in a collaborative database. Transthoracic echocardiography was performed at admission, as soon as possible. All studied parameters were available in each patient. AUC in ROC analysis were assessed for each parameter and were compared between them. Multivariable Cox regression analysis was performed to assess the combination of echo-parameters. Results Overall, 490 pts were included in the study (229F), aged 64±18 years. Clinical endpoint occurred in 31 pts including 8 APE related deaths. AUC for SAE of RV/LV, TAPSE and TRPG/TAPSE were similar (Figure 1). TAPSE &lt;16mm compared to other echo-parameters showed the highest PPV and NPV (Table 1). Cox regression analysis including SBP, HR, age, elevated troponin and echo-parameters showed that only blood pressure, RV/LV &gt;1 and TAPSE &lt;16mm were identified as independent predictors of outcome (HR 0.98 (95% CI: 0.96–0.99), p=0.03; 2,53 (95% CI: 1.2–5.7), p&lt;0.03 and 3,76 (95% CI: 1.74–8.11), p&lt;0.001). Table 1. Predictive values of proposed cut offs of echocardiographic parameters Parameter Sensitivity Specificity PPV NPV TAPSE &lt;16mm 52% 85% 18% 96% RV/LV &gt;1.0 74% 63% 12% 95% TAPSE&lt;20 &amp; TRPG/TAPSE &gt;4.5 10% 94% 10% 94% Figure 1 Conclusions Although all TAPSE, RV/LV ratio and TRPG/TAPSE showed similar performance for prognosticating of in-hospital outcome in normotensive PE patients, TAPSE&lt;16mm showed the highest predictive value for identification of patients at risk of complicated clinical course.

Hemodynamic Markers of Predominant Right Ventricular Dysfunction are Associated with Paradoxical Decreased Cell-Mediated Immunity in Patients with Advanced Heart Failure

Right ventricular dysfunction and decrease cellular immunity have been associated with worse prognosis in patients with advanced heart failure. Our objective was to evaluate if there was a relationship between hemodynamic parameters of right ventricular dysfunction and cell mediated immunity .

Echocardiographic parameters of right ventricular function predict mortality in acute respiratory distress syndrome: a pilot study.

Right ventricular (RV) dysfunction in acute respiratory distress syndrome (ARDS) contributes to increased mortality. Our aim is to identify reproducible transthoracic echocardiography (TTE) parameters of RV dysfunction that can be used to predict outcomes in ARDS. We performed a retrospective single-center cohort pilot study measuring tricuspid annular plane systolic excursion (TAPSE), Tei index, RV-fractional area change (RV-FAC), pulmonary artery systolic pressure (PASP), and septal shift, reevaluated by an independent blinded cardiologist (JK). Thirty-eight patients were included. Patients were divided on the basis of 30-day survival. Thirty-day mortality was 47%. Survivors were younger than nonsurvivors. Survivors had a higher pH, PaO2∶FiO2 ratio, and TAPSE. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were lower in survivors. TAPSE has the strongest association with increased 30-day mortality from date of TTE. Accordingly, TAPSE has a strong positive correlation with PaO2∶FiO2 ratios, and Tei index has a strong negative correlation with PaO2∶FiO2 ratios. Septal shift was associated with lower PaO2∶FiO2 ratios. Decrease in TAPSE, increase in Tei index, and septal shift were seen in the severe ARDS group. In multivariate logistic regression models, TAPSE maintained a significant association with mortality independent of age, pH, PaO2∶FiO2 ratios, positive end expiratory pressure, PCO2, serum bicarbonate, plateau pressures, driving pressures, APACHE II, SAPS II, and SOFA scores. In conclusion, TAPSE and other TTE parameters should be used as novel predictive indicators for RV dysfunction in ARDS. These parameters can be used as surrogate noninvasive RV hemodynamic measurements to be manipulated to improve mortality in patients with ARDS and contributory RV dysfunction.

Correlations between echocardiographic parameters of right ventricular dysfunction and Galectin-3 in patients with chronic obstructive pulmonary disease and pulmonary hypertension.

To evaluate the association between echocardiographic right ventricular (RV) structural and functional parameters and galectin-3 levels in patients with chronic obstructive pulmonary disease (COPD) and associated pulmonary hypertension presenting with acutely aggravated dyspnoea. We conducted a prospective study on forty patients with COPD and forty healthy volunteers matched for age and sex (mean age 59+/-6 years), measuring galectin-3 and NT-proBNP serum levels and specific echocardiographic parameters. Galectin-3 was significantly higher in patients with COPD and elevated systolic pulmonary artery pressure than in healthy volunteers and discriminated better between patients with likely and possible pulmonary hypertension when compared to NT-proBNP. In multivariate analysis, the global model was better related to galectin-3 than to NT-proBNP levels (R²=0.61 vs. 0.31, p<0.001). Moreover, in contrast to NT-proBNP levels, correlations between galectin-3 levels and RV dysfunction, as assessed by the E/E' ratio and RV ejection fraction, persisted after adjustment for cardiovascular risk factors and COPD-induced inflammation. In patients with COPD-associated pulmonary hypertension presenting with acutely aggravated dyspnoea, galectin-3 levels are predictive of RV dysfunction and correlate better with RV dysfunction parameters compared to NT-proBNP.

CT pulmonary angiography findings that predict 30-day mortality in patients with acute pulmonary embolism

PurposeStandard computed tomography pulmonary angiography (CTPA) can be used to diagnose acute pulmonary embolism. In addition, multiple findings at CTPA have been proposed as potential tools for risk stratification. Therefore, the aim of the present study is to examine the prognostic value of (I) thrombus distribution, (II) morphometric parameters of right ventricular dysfunction, and (III) contrast reflux in inferior vena cava on 30-day mortality. Material and methodsIn a retrospective, single-center study from 06/2005 to 01/2010 365 consecutive patients were included. Inclusion criteria were: presence of acute pulmonary embolism, and availability of 30-day follow-up. A review of patient charts and images was performed. ResultsThere were no significant differences between the group of 326 survivors and 39 non-survivors in (I) thrombus distribution, and (II) morphometric measurements of right ventricular dysfunction. However, (III) contrast reflux in inferior vena cava was significantly stronger in non-survivors (odds ratio 3.29; p<0.001). Results were independent from comorbidities like heart insufficiency and pulmonary hypertension. ConclusionMeasurement of contrast reflux is a new and robust method for predicting 30-day mortality in patients with acute pulmonary embolism. Obstruction scores and morphometric measurements of right ventricular dysfunction perform poor as risk stratification tools.

Clot burden score in the evaluation of right ventricular dysfunction in acute pulmonary embolism: Quantifying the cause and clarifying the consequences

IntroductionPulmonary angiography by computed tomography (CT) is the method of choice for the detection of acute pulmonary embolism (PE). Studies have shown that the severity of PE can be estimated by clot burden scores. ObjectiveTo evaluate the correlation between an angiographic clot burden score (Qanadli score–QS) and parameters of right ventricular dysfunction (RVD) in patients admitted for PE. MethodsWe performed a retrospective study of 107 patients (60% female) admitted to an intensive care unit for PE (intermediate/high risk) between January 1, 2007 and September 30, 2011. Images from 16-slice multidetector CT angiography were reviewed in 102 patients and the QS calculated. Based on a cut-off of 18 points established by ROC curve analysis, two groups were formed (A<18 points vs. B≥18 points) and the clinical, laboratory, ECG, echocardiographic and CT angiography parameters were compared. The statistical analysis was performed using SPSS. ResultsThe overall mean age was 61.4 years. With regard to symptoms at admission, there was a greater prevalence in group B of fatigue, chest pain and syncope (p=0.017), with higher Geneva and Wells scores and shock index.In terms of ECG parameters, heart rate and percentage of right bundle branch block, T-wave inversion (V1–V3) and S1Q3T3 pattern (p=0.034) were higher in group B, as was the ECG score (p=0.009).Laboratory tests revealed that group B had higher troponin and d-dimers, with lower creatinine clearance by the MDRD formula (p=0.020) and PO2/FiO2 ratio. Echocardiography showed higher pulmonary artery systolic pressure in group B, and CT angiography revealed larger right ventricular (RV) diameters and higher RV/LV ratio (p=0.002), and greater superior vena cava, azygos vein and coronary sinus diameters in this group. Pulmonary artery (PA) diameter and the PA/aorta ratio were similar. Interventricular septal bowing and reflux of contrast into the inferior vena cava (p=0.001) were greater in group B, and QS>18 was an independent predictor of RVD (RV/LV ratio>1) (OR: 10.85; p<0.001) (area under the curve on ROC analysis: 0.79; p<0.001).The percentage of patients receiving fibrinolytic treatment was higher in group B (p=0.045), and in-hospital mortality was similar in both groups (overall 4.9%). ConclusionsQS>18 points proved to be an independent predictor of RVD in PE, and correlated linearly with variables associated with higher morbidity and mortality.

O valor da carga embólica na avaliação de disfunção ventricular direita no tromboembolismo pulmonar agudo: quantificando a causa e clarificando as consequências

IntroductionPulmonary angiography by computed tomography (CT) is the method of choice for the detection of acute pulmonary embolism (PE). Studies have shown that the severity of PE can be estimated by clot burden scores. ObjectiveTo evaluate the correlation between an angiographic clot burden score (Qanadli score - QS) and parameters of right ventricular dysfunction (RVD) in patients admitted for PE. MethodsWe performed a retrospective study of 107 patients (60% female) admitted to an intensive care unit for PE (intermediate/high risk) between January 1, 2007 and September 30, 2011. Images from 16-slice multidetector CT angiography were reviewed in 102 patients and the QS calculated. Based on a cut-off of 18 points established by ROC curve analysis, two groups were formed (A<18 points vs. B ≥18 points) and the clinical, laboratory, ECG, echocardiographic and CT angiography parameters were compared. The statistical analysis was performed using SPSS. ResultsThe overall mean age was 61.4 years. With regard to symptoms at admission, there was a greater prevalence in group B of fatigue, chest pain and syncope (p=0.017), with higher Geneva and Wells scores and shock index.In terms of ECG parameters, heart rate and percentage of right bundle branch block, T-wave inversion (V1-V3) and S1Q3T3 pattern (p=0.034) were higher in group B, as was the ECG score (p=0.009).Laboratory tests revealed that group B had higher troponin and d-dimers, with lower creatinine clearance by the MDRD formula (p=0.020) and PO2/FiO2 ratio. Echocardiography showed higher pulmonary artery systolic pressure in group B, and CT angiography revealed larger right ventricular (RV) diameters and higher RV/LV ratio (p=0.002), and greater superior vena cava, azygos vein and coronary sinus diameters in this group. Pulmonary artery (PA) diameter and the PA/aorta ratio were similar. Interventricular septal bowing and reflux of contrast into the inferior vena cava (p=0.001) were greater in group B, and QS>18 was an independent predictor of RVD (RV/LV ratio>1) (OR: 10.85; p<0.001) (area under the curve on ROC analysis: 0.79; p<0.001). The percentage of patients receiving fibrinolytic treatment was higher in group B (p=0.045), and in-hospital mortality was similar in both groups (overall 4.9%). ConclusionsQS >18 points proved to be an independent predictor of RVD in PE, and correlated linearly with variables associated with higher morbidity and mortality.

Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: Correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome

PurposeTo investigate the prognostic value of perfusion defect volume (PDvol) at dual-energy-CT-angiography (DE-CTA) in patients with acute pulmonary embolism (PE) by correlating PDvol with CTA-obstruction-scores (OS), CT parameters of right-ventricular-dysfunction (RVD), and adverse-clinical-outcome. Materials and methodsDE-CTA of 60 patients (mean age: 65±14.4 years) with PE were analyzed. Iodine maps were generated, and normalized PDvol – defined as volume of perfusion defects/total lung volume – was quantified. Furthermore, established prognostic parameters (Qanadli and Mastora-OS, and CT parameters of RVD) were obtained. CT parameters of RVD – namely the right ventricle/left ventricle (RV/LV) diameter ratio measured on transverse sections (RV/LVtrans), four-chamber views (RV/LV4ch), and RV/LV volume ratios (RV/LVvol) – were assessed. PDvol was correlated with OS, CT parameters of RVD and adverse clinical outcome (defined as the need for intensive care treatment or death). Results10 of 60 patients with PE experienced adverse clinical outcome. Patients with adverse clinical outcome showed significantly higher PDvol (35±11% vs. 23±10%, p=0.002), RV/LV ratios (RV/LV4ch 1.46±0.32 vs. 1.18±0.26, p=0.005; RV/LVvol 2.25±1.33 vs. 1.19±0.56, p=0.002) and higher Mastora global scores (52 vs. 13, p=0.02) compared to those without adverse clinical outcome. A weak correlation was observed between PDvol and the Mastora global score (r=0.5; p=0.0003), as well as between PDvol and RV/LV4Ch (r=0.432, p=0.0006). No correlation was found between PDvol and the Qanadli score or the remainder of the RVD-CT parameters. ConclusionThe extent of perfusion defects as assessed by DE-CTA correlates with adverse clinical outcome in patients with PE. Therefore, volumetric quantification of perfusion defects at DE-CTA allows the identification of low-risk patients who do not require intensified monitoring and treatment.

Echocardiographic Parameters of Right Ventricular Dysfunction in Patients with Massive Pulmonary Embolism

Methods:All patients undergoingTAVI-C fromNovember 2008 to February 2010 were included in this study. Patients underwent detailed resting echo immediately prior to and one year post procedure. Objective clinical review including New York Heart Association (NYHA) functional class and Minnesota Living with Heart Failure Questionnaire (MLHFQ)wereperformedat the same time intervals. Results:Twenty-nine patientswith SSAS (22men, 83± 4 years) underwent TAVI-C. There was 100% procedural success with 14% one year mortality and a single rescue surgicalAVR.At one year, TAVI-C lead to an improvement NYHA class, quality of life and reduction in mean aortic gradient but no significant change in other measures of cardiac structure and function (see table). Conclusion: In selected patients with severe AS, TAVI leads to an improvement in NYHA functional class, quality of life and a reduction in mean aortic valve gradient at one year without any other significant impact on echo measures of cardiac function. Baseline 12 months p value MLHFQ score 39± 16 6± 6 <0.001 Median NYHA class 3 (1–4) 2 (1–4) <0.001 Mean AV gradient, mmHg 48± 14 9± 3 <0.001 Aortic regurgitation, grades 1–4 0.6± 0.6 0.5± 0.5 NS LV mass, g/m2 140± 27 138± 11 NS LV ejection fraction, % 58± 9 60± 10 NS Septal E′ , cm/s 4.2± 1.5 4.7± 1.3 NS Lateral E′ , cm/s 6.0± 2.0 7.1± 1.9 NS Results: Severe PAH was present in 64.5% (n= 40) patients. Abnormalities in ≥2 parameters on TTE in the severe PAH cohort was 100.0% vs. 68.2% (p< 0.001) in the non-severe cohort. Of the parameters, RV wall thickness (OR 6.0, p< 0.001) and RV S′ (OR1.9, p= 0.02) were found to have the most predictive value (ROC=0.96). Conclusions: The presence of any two abnormalities of RH size and function on echocardiography is highly sensitive but not specific for severe PAH. In particular the combination of increased RV wall thickness and reduced RV S′ were found to be strongly correlated with severe PAH. doi:10.1016/j.hlc.2011.05.427

CT imaging of acute pulmonary embolism

CT pulmonary angiography (CTPA) has become the de facto clinical "gold standard" for the diagnosis of acute pulmonary embolism (PE) and has replaced catheter pulmonary angiography and ventilation-perfusion scintigraphy as the first-line imaging method. The factors underlying this algorithmic change are rooted in the high-sensitivity and specificity, cost-effectiveness, and 24-hour availability of CTPA. In addition, CTPA is superior to other imaging methods in its ability to diagnose and exclude, in a single examination, a variety of diseases that mimic the symptoms of PE. This article reviews the current role of CTPA in the diagnosis of acute PE as well as more recent developments, such as the use of CT parameters of right ventricular dysfunction for patient prognostication and the assessment of lung perfusion with CT.

Correlation of right ventricular dysfunction parameters and pulmonary vascular obstruction score in acute pulmonary embolism in a porcine model

This paper aims to non-invasively determine right ventricular dysfunction parameters (RVDP) in acute pulmonary embolism (APE) and to correlate these parameters with a computed tomography (CT)-based pulmonary artery obstruction score (OS). In seven domestic pigs, magnetic resonance imaging (MRI) was performed before (n = 7) and after (n = 5) APE was induced. Analysis of relative changes in right ventricular stroke volume (RVSV%), output (RVO%), end-systolic (RVESV%), end-diastolic volume (RVEDV%), and heart rate (HR%) was performed. Additionally, for the determination of the OS, all animals underwent contrast-enhanced CT-pulmonary angiography. The CT-based OS correlated strongly with RVSV% (r = 0.9576; p = 0.0104) and RVO% (r = 0.9703; p = 0.0061). Contrarily, almost no correlation could be demonstrated for the OS and the increase of RVESV % (r = 0.3850; p = 0.5222), RVEDV% (r = 0.1830; p = 0.7683), and HR% (r = 0.5494; p = 0.3375). The results of this experimental study underline that the CT-based OS correlates with RVDP as determined by cardiac MRI and might be a helpful tool for the severity assessment in APE.