Pulmonary Thromboembolic Disease Research Articles

Prognostic Implications of Abnormal Left-Right Lung Perfusion Differential on Routine Post-Transplant Ventilation-Perfusion Scans

<h3>Purpose</h3> Lung ventilation-perfusion (VQ) scans can be used to diagnose pulmonary thromboembolic disease as well as for surgical planning and monitoring after lung transplant, but the long-term implications of abnormalities on routine post-transplant studies are unknown. The relative lung perfusion distribution obtained from VQ scans estimates pulmonary blood flow, with up to a 10% difference (55%-45% right-to-left) considered normal. We hypothesized that unbalanced lung perfusion on 3-months post-transplant VQ scans would be associated with poorer long-term survival and increased frequency or severity of chronic lung allograft (CLAD) and baseline lung allograft dysfunction (BLAD). <h3>Methods</h3> We studied routine 3 month VQ scans from double lung transplant recipients in our program between 2004-2016. Abnormal perfusion differential was deemed ≥10%. We used Kaplan Meier estimation with log rank tests to assess the association with survival as well as CLAD onset and Fisher's Exact test and Cochran-Armitage trend testing to test the relationship to baseline lung allograft dysfunction. <h3>Results</h3> Of 340 patients who met inclusion criteria, 169 (49%) had a relative perfusion differential of at least 10% on their 3-months VQ scans. Patients with increased perfusion differential had longer hospital stays (24 days vs. 21 days; p=0.004), poorer overall survival (Figure 1, p=0.011) and increased CLAD onset (p=0.012). Increased perfusion differential was also associated with increased risk of BLAD (42% vs. 32%; p=0.043) and higher grade BLAD (p=0.006). <h3>Conclusion</h3> Abnormal relative lung perfusion differential is common after lung transplant and associated with increased risk of death, poor post-transplant baseline function and CLAD onset. This measurement warrants further exploration as a potential predictor of future lung dysfunction and related risk.

Predictors of survival in patients with precapillary pulmonary hypertension

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although the perceived prognosis of patients with precapillary pulmonary hypertension (PH) is poor, the natural history of this condition is very heterogeneous. In this study we sought to identify predictors of poor outcomes which could help refine prognosis. Methods We studied consecutive patients referred to our centre from 12/2016 to 11/2018 with confirmed precapillary PH. A range of clinical, laboratory, echocardiographic and right heart catheterization (RHC) data variables were collected to assess predictors of survival. Outcome was defined as mortality from any cause. Results Of the 80 included patients, 51 (64%) were female and mean age was 60.5 ± 16.0 years. The majority of patients (45%) had pulmonary arterial hypertension (group 1) and 41% were chronic thromboembolic pulmonary hypertensive disease patients (group 4). During a median follow-up of 18.7 [IQR 12.3 – 26.7] months, 10 patients (12.5%) died. New York Heart Association (NYHA) functional class (HR 19.4 [95% CI 2.56 - 147.5], p = 0.004) was the strongest predictor of mortality, whereas higher haemoglobin (HR 0.70 [0.49 - 0.99], p= 0.047) and 6-minute walking distance (6MWD) expressed as percentage of predicted (HR 0.96 [0.93 - 0.99], p = 0.004) were associated with better survival overall. Echocardiographic parameters such as eccentricity index (HR 3.35 (95% CI 1.11 - 10.0), p = 0.031), short pulmonary acceleration time (HR 0.98 [95% CI 0.96 - 0.99], p = 0.008), the presence of moderate to severe tricuspid regurgitation (HR 6.46 [95% CI 1.67 - 25.0], p = 0.007) and pericardial effusion (HR 3.86 [95% CI 1.12 - 13.4], p = 0.033) were also associated with death. Traditional right ventricular function parameters such as fractional area change, tricuspid annular plane systolic excursion (TAPSE) and S velocity of the lateral annular tricuspid annulus did not predict mortality in these patients. Invasive pressures and pulmonary vascular resistance measured by RHC were also not associated with mortality. In multivariable analysis, NYHA functional class was the only independent predictor of mortality in patients with precapillary PH (HR 14.5 [95% CI 2.3 - 146.8], p = 0.006). Conclusion Eccentricity index, short pulmonary acceleration time, moderate to severe tricuspid regurgitation and pericardial effusion were associated with poor survival. Functional class was the strongest independent predictor of mortality in precapillary PH patients. These parameters may help stratify the risk of death in this heterogenous population.

Determinants and Management of the Post-Pulmonary Embolism Syndrome.

Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.

Forensic Analysis of 105 Autopsy Cases of Psychiatric Patients.

Objective To provide reference for medical and health services and forensic expertise, the causes and manners of death of psychiatric patients were analyzed retrospectively. Methods A total of 105 autopsy cases of psychiatric patients accepted and settled by Institute of Forensic Science of Criminal Investigation Police University of China from 2004 to 2019 were collected. The cases were divided into four groups： disease death, suicidal death, accidental death and homicidal death. The common causes of death of each group were statistically analyzed and the differences in age, disease duration, body mass index （BMI） and gender among the groups were assessed. Results Of the 105 cases, 60 were male and 45 were female, the course of psychosis was （12.9±10.4） years, the age of the deceased was （51.3±11.4） years, and 61.0% was schizophrenic. There were 50 cases （47.6%） in the disease death group, in which the psychiatric patients were the oldest and had the longest course of psychosis and lowest BMI. Pulmonary thromboembolism, respiratory infections, and cardiogenic disease were the most common causes of death in the group. There were 26 accidental deaths （24.8%）, among which traffic accidents were the most common cause of death. There were 15 homicidal deaths （14.3%）, all of which were male, with craniocerebral injury being the most common cause of death. There were 14 suicidal deaths （13.3%）. In suicidal death group, the age of the deceased was the youngest, the course of psychosis was the shortest and falling from the height was the most common way to commit suicide. Conclusion Understanding the common causes of death of psychiatric patients may contribute to developing measures to reduce the mortality rate of the population. It is necessary to investigate the age, course of psychosis and gender of the deceased when assessing the manner of death.

Radiological differences between chronic thromboembolic pulmonary disease (CTEPD) and chronic thromboembolic pulmonary hypertension (CTEPH)

ObjectivesThe aim of this study was to describe the radiological features of chronic thromboembolic pulmonary disease (CTEPD), not yet systematically described in the literature. Furthermore, we compared vascular scores between CTEPD and chronic thromboembolic pulmonary hypertension (CTEPH) patients, trying to explain why pulmonary hypertension does not develop at rest in CTEPD patients.MethodsEighty-five patients (40 CTEPD, 45 CTEPH) referred to our centre for pulmonary endarterectomy underwent dual-energy computed tomography pulmonary angiography (DE-CTPA) with iodine perfusion maps; other 6 CTEPD patients underwent single-source CTPA. CT scans were reviewed independently by an experienced cardiothoracic radiologist and a radiology resident to evaluate scores of vascular obstruction, hypoperfusion and mosaic attenuation, signs of pulmonary hypertension and other CT features typical of CTEPH.ResultsVascular obstruction burden was similar in the two groups (p = 0.073), but CTEPD patients have a smaller extension of perfusion defects in the iodine map (p = 0.009) and a smaller number of these patients had mosaic attenuation (p < 0.001) than CTEPH patients, suggesting the absence of microvascular disease. Furthermore, as expected, the two groups were significantly different considering the indirect signs of pulmonary hypertension (p < 0.001).ConclusionsCTEPD and CTEPH patients have significantly different radiological characteristics, in terms of signs of pulmonary hypertension, mosaic attenuation and iodine map perfusion extension. Importantly, our results suggest that the absence of peripheral microvascular disease, even in presence of an important thrombotic burden, might be the reason for the absence of pulmonary hypertension in CTEPD.Key Points• CTEPD and CTEPH patients have significantly different radiological characteristics.• The absence of peripheral microvascular disease might be the reason for the absence of pulmonary hypertension in CTEPD.

Patterns of thromboembolic pulmonary vascular disease in COVID-19.

SARS-CoV-2 (COVID-19) is associated with increased thrombosis. Here, we demonstrate patterns of pulmonary vascular disease in COVID-19 including classical acute pulmonary embolism and subsegmental perfusion defects in the absence of acute pulmonary embolism suggestive of microvascular thrombosis.

Thrombotic Lesion of the Pulmonary Vessels in Patients with Pulmonary Embolism

After suffering pulmonary embolism (PE), doctors are confronted with various consequences of the disease, from asymptomatic residual pulmonary thrombosis to the formation of chronic thromboembolic pulmonary hypertension (CTEPH). There is also a subgroup of patients who have undergone pulmonary embolism, who experience shortness of breath during physical exertion, absent before pulmonary embolism, or shortened dyspnea preceding PE, combined with residual thrombosis of pulmonary artery (PA) and normal average pressure in PA at rest during catheterization of the right heart (CRH). This condition is defined as chronic thromboembolic pulmonary disease or post thromboembolic syndrome. Pathogenetic aspects of this condition are not fully investigated. It is important to predict the development of postembolic syndrome and to develop algorithms for the diagnosis, treatment and rehabilitation of patients with symptoms and residual pulmonary thrombosis. In case of the development of pulmonary vasculopathy in some patients who have undergone pulmonary embolism, a severe life-threatening condition forms - CTEPH, characterized by an increase in pressure in the pulmonary artery, right heart failure due to the presence of organized blood clots that have entered the pulmonary vascular bed during PE. The volume of thrombotic masses does not always correlate with clinical symptoms, which indicates the importance of microvascular remodeling. If CTEPH is suspected, a diagnostic algorithm is required, including ventilation-perfusion scintigraphy, CT angiopulmonography and catheterization of the right heart. Treating a patient with CTEPH is a difficult task fora doctor. The timely referral of the patient to the center where they are involved in treatment, including surgery and CTEPH is extremely important. Timely performed thrombendarterectomy in some cases allows to completely cure the patient. In the case of inoperable CTEPH or residual pulmonary hypertension after thrombendarterectomy, balloon angioplasty of the PA is used as well as drug treatment with specific drugs that reduce the pressure in the PA (riociguat), endothelin receptor antagonists (bosentan, macitentan), prostanoids (inhalant illoprost) phosphodiesterase-5 inhibitor and combined therapy. In this article we considered some consequences directly related to PE: asymptomatic residual pulmonary thrombosis, chronic thromboembolic pulmonary disease, chronic thromboembolic pulmonary hypertension.

Pulmonary thromboembolic disease in COVID-19 patients on CT pulmonary angiography – Prevalence, pattern of disease and relationship to D-dimer

ObjectivesTo define the prevalence of pulmonary thromboembolic (PTE) disease diagnosed on CT pulmonary angiography (CTPA) in COVID-19 patients. To assess distribution of PTE and to evaluate for association between severity of COVID-19 disease, D-dimer values and incidence of PTE. MethodsPatients with diagnosis of COVID-19 presenting to 5 different hospitals across Greater Manchester between 1st March 2020 and 30th April 2020 who had CTPA were included. CTPA images were evaluated for presence of PTE, distribution of PTE (in small and/or large vessels) and distribution of PTE within lungs with or without COVID-19 CT changes. Severity of COVID lung changes were graded. D-dimer values within 72 h of CTPA were obtained. Statistical analyses were performed to evaluate for any significant association between variables. p values of ≤0.05 were regarded as statistically significant. ResultsA total of 974 patients presented across five hospital sites with COVID-19 infection. Eighty-four (n = 84) COVID-19 patients underwent CTPA. Of these, 38 % (32/84) had PTE. PTE was seen in small vessels in 75 % (24/32) and in lungs demonstrating COVID-19 changes in 72 % (23/32). 84 % (27/32) of PTE positive patients had disease severity of moderate or higher score (p = 0.005). D-dimer values were significantly higher (p ≤ 0.001) in PTE patients, median value in PTE group was 6441mcg/L (range 219-90925). A D-dimer cut off value of 2247mcg/L provides sensitivity of 0.72 and specificity of 0.74. ConclusionThere is increased prevalence of PTE in patients with moderate to severe COVID-19 disease. D-dimer values may have potential in guiding anticoagulation therapy and prognostication.

Rescue therapy with thrombolysis in patients with severe COVID-19-associated acute respiratory distress syndrome.

Acute respiratory distress syndrome in patients with Coronavirus disease 19 is associated with an unusually high incidence of pulmonary embolism and microthrombotic disease, with evidence for reduced fibrinolysis. We describe seven patients requiring invasive ventilation for COVID-19-associated acute respiratory distress syndrome with pulmonary thromboembolic disease, pulmonary hypertension ± severe right ventricular dysfunction on echocardiography, who were treated with alteplase as fibrinolytic therapy. All patients were non-smokers, six (86%) were male and median age was 56.7 (50–64) years. They had failed approaches including therapeutic anticoagulation, prone ventilation (n = 4), inhaled nitric oxide (n = 5) and nebulised epoprostenol (n = 2). The median duration of mechanical ventilation prior to thrombolysis was seven (5–11) days. Systemic alteplase was administered to six patients (50 mg or 90 mg bolus over 120 min) at 16 (10–22) days after symptom onset. All received therapeutic heparin pre- and post-thrombolysis, without intracranial haemorrhage or other major bleeding. Alteplase improved PaO2/FiO2 ratio (from 97.0 (86.3–118.6) to 135.6 (100.7–171.4), p = 0.03) and ventilatory ratio (from 2.76 (2.09–3.49) to 2.36 (1.82–3.05), p = 0.011) at 24 h. Echocardiographic parameters at two (1–3) days (n = 6) showed right ventricular systolic pressure (RVSP) was 63 (50.3–75) then 57 (49–66) mmHg post-thrombolysis (p = 0.26), tricuspid annular planar systolic excursion (TAPSE) was unchanged (from 18.3 (11.9–24.5) to 20.5 (15.4–24.2) mm, p = 0.56) and right ventricular fractional area change (from 15.4 (11.1–35.6) to 31.2 (16.4–33.1)%, p = 0.09). At seven (1–13) days after thrombolysis, using dual energy computed tomography imaging (n = 3), average relative peripheral lung enhancement increased from 12.6 to 21.6% (p = 0.06). In conclusion, thrombolysis improved PaO2/FiO2 ratio and ventilatory ratio at 24 h as rescue therapy in patients with right ventricular dysfunction due to COVID-19-associated ARDS despite maximum therapy, as part of a multimodal approach, and warrants further study.

Antiphospholipid syndrome with chronic thromboembolic pulmonary hypertension and coronary artery disease: a case report

BackgroundAntiphospholipid syndrome (APS) is characterized by the production of antiphospholipid antibodies associated with recurrent vascular thrombosis. There have been few reports of combination of chronic thromboembolic pulmonary hypertension (CTEPH) and coronary artery disease in APS, therefore, it is unclear about appropriate treatment strategy.Case presentationThe patient was a 39 year-old-lady who had been suffering from hypoxia without chest pain. Transthoracic echocardiography showed severe pulmonary hypertension and mild hypokinesis of left ventricular anteroseptal wall. Simultaneously with the diagnosis of CTEPH, coronary angiography revealed severe stenosis of the left anterior descending artery. She underwent pulmonary endarterectomy (PEA) concomitant with coronary artery bypass grafting (CABG) successfully. CABG could be performed concomitantly during rewarming. During perioperative period, she was free from any thromboembolic and bleeding events despite receiving anticoagulant and antiplatelet therapies.ConclusionsPEA concomitant with coronary artery bypass grafting was feasible for APS patients complicated with CTEPH and coronary artery disease. APS patients with the presence of left ventricular dysfunction should be evaluated for coronary artery disease.

Extent of pulmonary thromboembolic disease in patients with COVID-19 on CT: relationship with pulmonary parenchymal disease

AIMTo report the severity and extent of pulmonary thromboembolic disease (PTD) in COVID-19 patients undergoing computed tomography pulmonary angiography (CTPA) in a tertiary centre.MATERIALS AND METHODSThis is a retrospective analysis of COVID-19 patients undergoing CTPA over a period of 27 days. The presence, extent, and severity of PTD were documented. Two observers scored the pattern and extent of lung parenchymal disease including potential fibrotic features, as well as lymph node enlargement and pleural effusions. Consensus was achieved via a third observer. Interobserver agreement was assessed using kappa statistics. Student's t-test, chi-squared, and Mann–Whitney U-tests were used to compare imaging features between PTD and non-PTD sub-groups.RESULTSDuring the study period, 100 patients with confirmed COVID-19 underwent CTPA imaging. Ninety-three studies were analysed, excluding indeterminate CTPA examinations. Overall incidence of PTD was 41/93 (44%) with 28/93 patients showing small vessel PTD (30%). D-dimer was elevated in 90/93 (96.8%) cases. A high Wells' score did not differentiate between PTD and non-PTD groups (p=0.801). The interobserver agreement was fair (kappa=0.659) for parenchymal patterns and excellent (kappa=0.816) for severity. Thirty-four of the 93 cases (36.6%) had lymph node enlargement; 29/34 (85.3%) showed no additional source of infection. Sixteen of the 93 (17.2%) cases had potential fibrotic features.CONCLUSIONThere is a high incidence of PTD in COVID-19 patients undergoing CTPA and lack of a risk stratification tool. The present data indicates a higher suspicion of PTD is needed in severe COVID-19 patients. The concomitant presence of possible fibrotic features on CT indicates the need for follow-up.

Pulmonary Artery Sarcoma Diagnosed by Transbronchial Endosonographic (EBUS-TBNA) Approach

Background: Pulmonary Artery Sarcomas are the rarest and the most aggressive vascular tumors. Their accurate diagnosis is challenging due to the lack of specific symptoms and clinical manifestations and they are often initially misdiagnosed and managed as chronic pulmonary thromboembolic disease until an alternate diagnosis is suspected based on the lack of response to anticoagulants. Proper management is thus often delayed until histological confirmation. Moreover, the lack of consensus regarding their diagnosis and treatment further contributes to their reported high mortality [1]. Case Presentation: We present the case of a 34-year-old male, nonsmoker, who presented with hemoptysis, fatigue and dyspnea on exertion 3 months prior to admission. His chest x-ray showed enlargement of the left hilum and chest CT revealed a large intraluminal low attenuation filling defect at the level of the left PA. Chest MRI confirmed the presence of a large endovascular tumor of the left PA. Before referring the patient for surgical biopsy, he underwent bronchoscopy during which the vascular tumor was successfully located, observed and sampled by endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA). Tissue biopsy through EBUS-TBNA revealed an intimal sarcoma of the PA. The patient was subsequently referred for surgical excision with curative intent. Conclusion: Bronchoscopy and EBUS-TBNA may safely and accurately diagnose even rare pathologies of the mediastinal vasculature adjacent to the airways through transbronchial approach.

Aetiology and outcomes of severe right ventricular dysfunction.

Right ventricular dysfunction (RVD) is an important determinant of functional status and survival in various diseases states. Data are sparse on the epidemiology and outcome of patients with severe RVD. This study examined the characteristics, aetiology, and survival of patients with severe RVD. Retrospective study of consecutive patients with severe RVD diagnosed by transthoracic echocardiography (TTE) between 2011 and 2015 in a single tertiary referral institution. Patients with prior cardiac surgery, mechanical assist devices, and congenital heart disease were excluded. Primary endpoint was all-cause mortality. In 64728 patients undergoing TTE, the prevalence of ≥mild RVD was 21%. This study focused on the cohort of 1299 (4%) patients with severe RVD; age 64 ± 16 years; 61% male. The most common causes of severe RVD were left-sided heart diseases (46%), pulmonary thromboembolic disease (18%), chronic lung disease/hypoxia (CLD; 17%), and pulmonary arterial hypertension (PAH; 11%). After 2 ± 2 years of follow-up, 701 deaths occurred, 66% within the first year of diagnosis. The overall probability of survival at 1- and 5 years for the entire cohort were 61% [95% confidence interval (CI) 58-64%] and 35% (95% CI 31-38%), respectively. In left-sided heart diseases, 1- and 5-year survival rates were 61% (95% CI 57-65%) and 33% (95% CI 28-37%), respectively; vs. 76% (95% CI 68-82%) and 50% (95% CI 40-59%) in PAH, vs. 71% (95% CI 64-76%) and 49% (95% CI 41-58%) in thromboembolic diseases, vs. 42% (95% CI 35-49%) and 8% (95% CI 4-15%) in CLD (log-rank P < 0.0001). Presence of ≥moderate tricuspid regurgitation portended worse survival in severe RVD. One-year mortality of patients with severe RVD was high (∼40%) and dependent on the aetiology of RVD. Left-sided heart diseases is the most common cause of severe RVD but prognosis was worst in CLD.

Examination of pulmonary embolism inpatients in a university hospital

Aim: Pulmonary embolism (PE) is responsible for 5-15% of hospital deaths. The rate of mortality from PE in untreated cases is about 25-30%, while this rate drops down to 2-8% in treated cases. In this study, we aimed to investigate general features of the patients hospitalized in our center due to PE and the factors affecting prognosis. Material and Methods: Patients hospitalized due to PE in Harran University Medical Faculty Hospital between January 2015 and December 2017. Patients’ demographic data, comorbidities, hemogram outcomes at the time of admission, liver function tests, renal function tests, electrolytes and cardiac markers, status of the patients during follow-up (referral to intensive care unit, exitus, ward follow-up) and PE clinical picture (massive, submassive, nonmassive) were recorded. All patients requiring hospitalization due to PE were included in the study, while patients with chronic thromboembolic pulmonary disease, those requiring recurrent hospitalization and patients discharged on own demand were excluded from the study.Results: The study included 40 (38.8%) male and 63 (61.2%) female patients with a mean age of 66±18.1 years. The mean duration of hospitalization was found as 11 days. Of the patients included in this study, 7.7% (n=8) were diagnosed with massive, 10.6% (n=11) with submassive, and 81.5% (n=84) with non-massive PE. Four patients (3.8%) were accepted as in-hospital exitus, 30 (29.1%) patients were transferred to the intensive care unit and 69 (66.9%) patients were followed-up in the thoracic diseases service. When patients diagnosed with non-massive PE were compared with those diagnosed with submassive and massive PE; the levels of magnesium (p=0.003), and troponin (p=0.000) were statistically significantly higher in the group diagnosed with submassive and massive PE. When the groups with and without the need for intensive care were compared, platelet counts were statistically lower in the group which required intensive care (p=0.038).Conclusion: More often hospitalization is needed in female patients due to PE. Although routine laboratory tests give a partial information about the prognosis of PE, cardiac markers are the most commonly used in clinical practice.

“The post-pulmonary syndrome - results of echocardiographic driven follow up after acute pulmonary embolism”

IntroductionThe concept of post Pulmonary Embolism syndrome includes various combinations of functional, haemodynamic or imaging abnormalities in patients after pulmonary embolism (PE). Although residual obstruction of pulmonary vascular bed is suggested to be a major cause of post Pulmonary Embolism syndrome (post-PE syndrome) other cardiopulmonary abnormalities can be responsible for functional impairment. Therefore, we analyzed the frequency of post-PE syndrome and its potential causes. Material and methodsWe report data of consecutive 845 PE survivors (468 F, aged 62 ± 18 yrs) who were anticoagulated, and followed for at least 6 months. All symptomatic subjects at follow up underwent diagnostic workup. Results35% (290/845) of PE survivors recovered functionally, while 65% patients reported a decreased exercise tolerance compatible with post-PE syndrome. One hundred and five symptomatic cases were lost to follow up. After diagnostic workup, chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed in 38 of 450 (8.4%) symptomatic subjects and chronic thromboembolic pulmonary disease (CTED) was diagnosed in 15/450 (3.3%) of them. Chronic heart failure with reduced ejection fraction (EF) was found in 6.9% (31/450) of patients and 154 patients (34.2%) had leftsided diastolic dysfunction. Valve heart disease was detected in 6.2% (28/450), atrial fibrillation in 31/450 (6.9%), Other causes of reduced exercise tolerance include coronary artery disease in 31/450 (6.9%), pulmonary disease 42/450 (9.3%), morbid obesity 15/450 (3.3%), neoplasms 15/450 (3.3%), psychiatric disorders 1%, rheumatoid disease 1%, anemia 1%. ConclusionsApproximately 65% of PE survivors report functional impairment, despite at least 6 months of anticoagulation. Persistent pulmonary artery thromboemboli resulting in CTEPH or CTED were detected in 7.2% of PE survivors and 11.8% of symptomatic patients. Leftsided diastolic dysfunction was the most prevalent echocardiographic abnormality, and remained the most common cause of functional limitation affected 34.2% of symptomatic cases.

P2768Post-PE impairment is mostly related to newly diagnosed heart failure with preserved ejection fraction

Abstract Introduction Recently, the concept of post-PE impairment (PPEI) was proposed which includes various combinations of functional, haemodynamic or imaging abnormalities in patients after acute pulmonary embolism (PE). Chronic residual obstruction of pulmonary vascular bed, despite adequate anticoagulation, is suggested to be a major cause of PPEI. Material and methods We report data of consecutive 700 PE survivors (390 F, aged 62±18 yrs). In all patients PE was diagnosed and treated according to ESC recommendations. Patients were anticoagulated and followed for at least 6 months in outpatient clinic (median 6, 6–18 months). All symptomatic subjects underwent detailed diagnostic workup which included standardized echocardiography, lung scintigraphy, pulmonary functional tests, and chest CT, RHC and coronary angiography when appropriate. Results 207/700 (29,6%) of PE survivors completely recovered functionally. However, when compared to prePEperiod 493/700 (70,4%) patients reported functional limitation compatible with PPEI. Exertional dyspnoea was present in 36,5% of symptomatic patients, then 25,5% others presented effort angina with or without dyspnoea, 11% of symptomatic patients reported palpitations and 27% complained of reduced exercise tolerance. After diagnostic workup, CTEPH was diagnosed in 38 of 493 (7,7%) symptomatic subjects (5,4% of all survivors) and chronic thromboembolic pulmonary disease (CTED) in 12/493 (2,4%) of them. 52,9% pts have chronic heart failure with reduced ejection fraction (EF) 4,2% and 37,2% with preserved EF; valve heart disease was detected in 8,9% and significant arrhythmia, mostly atrial fibrillation, in 2,6%. Breathlessness and reduce exercise tolerance in the others were caused by coronary artery diseases or non-cardiovascular pathologies (e.g. anaemia, pulmonary disease). Conclusions Follow-up demonstrated that after an episode of PE, approximately 70% of patients report functional impairment. Although persistent pulmonary artery thromboemobli resulting in CTEPH or CTED were detected in 7,1% of PE survivors and 10% of symptomatic patients. Left ventricular diastolic dysfunction is the most common cause of PPEI.

Imaging Pulmonary Embolic Disease

The purpose of this article is to review the imaging findings and current imaging techniques of acute pulmonary embolism (PE) and chronic thromboembolic disease. Special considerations are also discussed, including pregnancy, congenital heart disease, lower extremity computed tomography (CT), and the isolated subsegmental PE. CT pulmonary angiography and planar ventilation/perfusion (V/Q) lung scintigraphy are the primary means of evaluating pulmonary embolic disease. Magnetic resonance angiography avoids ionizing radiation and iodinated contrast in select patients. V/Q SPECT/CT provides greater accuracy and fewer non-diagnostic exams than planar V/Q scans. Dual-energy CT may prove valuable in the diagnosis of and preoperative planning for chronic thromboembolic pulmonary hypertension. Imaging plays a central role in identifying thromboembolic disease, but understanding the benefits and limitations when choosing the appropriate modality is imperative. Further research is needed to elucidate the role of emerging technologies in the assessment of thromboembolic disease.

IodiNe Subtraction mapping in the diagnosis of Pulmonary chronIc thRomboEmbolic disease (INSPIRE): Rationale and methodology of a cross-sectional observational diagnostic study

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe but treatable disease that is commonly underdiagnosed. Computed tomography lung subtraction iodine mapping (CT-LSIM) in addition to standard CT pulmonary angiography (CTPA) may improve the evaluation of suspected chronic pulmonary embolism and improve the diagnostic pick up rate. We aim to recruit 100 patients suspected of having CTEPH and perform CT-LSIM scans in addition to the current gold standard test of nuclear medicine test (lung single photon emission computed tomography (SPECT) imaging) as a pilot study which will contribute to and inform the definitive trial. The diagnostic accuracy of CT-LSIM and lung SPECT will be compared. The primary outcome of the full definitive study is non-inferiority of CT-LSIM versus lung SPECT imaging.

Clinical relevance of chronic respiratory disease in Korean patients with pulmonary thromboembolism.

Data regarding clinical and radiological features of patients with pulmonary thromboembolism (PTE) and concomitant chronic respiratory disease (CRD) are limited. Accordingly, the aim of the present study was to investigate clinico-radiological features of this patient population. Patients with PTE were retrospectively classified into one of two groups: those with and without CRD. Clinical characteristics, blood biomarkers, and computed tomographic (CT) findings were compared between the groups. Of 1,207 PTE patients included, CRD was detected in 128 (11%). The most common CRD was chronic obstructive pulmonary disease [41 (32%)], followed by bronchial anthracofibrosis [32 (25%)]. In multivariate analysis, unprovoked PTE [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.29-3.05, P=0.002], dyspnea (OR 1.54, 95% CI: 1.11-2.34, P=0.041), lower respiratory tract infection (LRTI) (OR 3.90, 95% CI: 2.13-7.14, P<0.001), Pulmonary Embolism Severity Index (PESI) class IV-V (OR 5.24, 95% CI: 3.43-8.00, P<0.001), in-situ pulmonary artery thrombosis (OR 10.62, 95% CI: 3.71-30.45, P<0.001), and pulmonary artery enlargement (OR 1.65, 95% CI: 3.71-30.45, P<0.001) were found to be independent clinical factors related to CRD in patients with PTE. CRD was an independent predictor of PTE-related in-hospital mortality (OR 3.96, 95% CI: 1.32-11.88, P=0.014). Patients with PTE and concomitant CRD were characterized by higher incidences of dyspnea, LRTI, PESI class IV-V, and in-situ pulmonary artery thrombosis, compared with non-CRD patients. In these patients, CRD was a predictor of PTE-related in-hospital mortality.

Letter from France

Letter from France