Right Ventricular-to-left Ventricular Research Articles

Gestational Age-Specific Markers Associated with Postnatal Intervention in Fetal Suspicion of Coarctation of the Aorta.

Fetal diagnosis of coarctation of the aorta (CoA) is currently associated with a high false-positive rate. Many predictive markers may be gestational age (GA)-specific. We sought to establish GA-specific traditional and speckle-tracking fetal echocardiography (STE) markers predictive of true CoA in neonates with prenatal suspicion. This is a retrospective case-control study. We compared the fetal ventricular and arch dimensions, as well as the deformation parameters by STE, of infants who required a postnatal intervention for their CoA with those who did not. Cohort was stratified based on GA before or after 30 weeks. Data extractors were masked to the outcome. The first fetal echocardiogram available was used. Seventy-five newborns with a fetal echocardiography performed between October 2013 and May 2022 for an antenatal suspicion of CoA were included, of which 59 (79%) had an aortic arch with nonsignificant obstruction upon ductal closure, and 16 (21%) underwent a neonatal intervention for a confirmed CoA. Before 30 weeks' GA, the right ventricular to left ventricular (RV/LV) end-diastolic width and end-diastolic area (EDA) ratios were most associated with postnatal CoA confirmation (area under the curve [AUCs] = 0.96 and 0.92). After 30 weeks' GA, the RV/LV end-diastolic width ratio (AUC = 0.95), the Z-score for the ascending aorta (AUC = 0.93), and the LV end-diastolic width Z-score (AUC = 0.91) performed the best. A decreased RV peak longitudinal strain was observed in those who developed true CoA and performed well by receiver operating characteristic analysis after 30 weeks (AUC = 0.85). In the overall cohort, the RV/LV EDA ratio was the most sensitive predictor of CoA and identified all cases with CoA. Indeed, a cutoff > 1.24 had a specificity of 69.5% and a sensitivity of 100% (receiver operating characteristic curve with an AUC of 0.88). We outlined sensitive and specific fetal markers associated with postnatal CoA based on GA at suspicion. · Fetal ventricular disproportion predicts postnatal coarctation.. · A decreased right ventircular contraction was observed in those with coarctation.. · Fetal markers differ based on gestational age at fetal evaluation..

Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p=0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

Radiological cardiothoracic ratio as a potential predictor of right ventricular enlargement in patients with suspected pulmonary embolism due to COVID-19

Abstract Funding Acknowledgements Type of funding sources: None. Objective. Cases of pulmonary embolism are observed in the course of COVID-19. Right ventricular enlargement is a negative prognostic factor of pulmonary embolism. The cardiothoracic ratio is a routine parameter in the cardiac assessment in chest radiology. Purpose. The aim of the study was to determine the usefulness of the radiological cardiothoracic ratio (CTR) as a predictor of right ventricular enlargement in patients with suspected pulmonary embolism during COVID-19. Material and method. The study group consisted of 61 patients with confirmed COVID-19, suspected of pulmonary embolism based on physical examination and laboratory tests (age: 67.18 ± 12.47 years). Computed tomography angiography (CTA) of pulmonary arteries and chest radiograph in AP projection with cardiothoracic ratio assessment were performed in all patients. Right ventricular enlargement was diagnosed by the ratio of right ventricular to left ventricular (RV/LV) dimensions in pulmonary CTA with 2 cut-off points: ≥0.9 and ≥1.0. Heart’s silhouette enlargement was found when CTR on the chest radiograph in the projection AP &amp;gt;0.55. Results. The mean values of RV/LV and CTR in the studied group were 0.96 ± 0.23 and 0.57 ± 0.05. Pulmonary embolism was diagnosed in 45.9%. Right ventricular enlargement was documented in 44.3% or 29.5% depending on the adopted criterion RV/LV ≥0.9 or RV/LV ≥1.0. Heart’s silhouette enlargement was found in 60.6%. Patients with confirmed pulmonary embolism (PE+) had significantly higher RV/LV ratio and CTR than patients with excluded pulmonary embolism (PE-) (RV/LV: PE+ 1.08 ± 0.24, PE- 0.82 ± 0.12; CTR: PE+ 0.60 ± 0.05, PE- 0.54 ± 0.04; p &amp;lt; 0.05). The correlation analysis showed a statistically significant positive correlation between RV/LV ratio and CTR (r = 0.59, p &amp;lt; 0.05). Based on the ROC curves, CTR values were determined as the optimal cut-off points for the prediction of right ventricular enlargement (RV/LV ≥0.9 or RV/LV ≥1.0), being 0.54 and 0.55, respectively. The sensitivity, specificity, and accuracy of the CTR criterion &amp;gt;0.54 as a predictor of RV/LV ratio ≥0.9 was 0.412, 0.963, and 0.656, respectively, while the CTR criterion &amp;gt;0.55 as a predictor of RV/LV ratio ≥1.0 was 0.488, 0.833, and 0.590, respectively. Conclusions. In patients with suspected pulmonary embolism during COVID-19, radiographic cardiothoracic ratio may be a predictor of right ventricular enlargement, especially a negative predictor of right ventricular enlargement in case of lower CTR values.

Utilization of EKOS in Patients With Pulmonary Embolism.

Objective: Current guidelines recommend utilization of catheter-directed thrombolysis systems for management of patients with submassive pulmonary embolism (PE) who have relative contraindications to systemic thrombolysis. Evidence from previous trials have demonstrated the short-term efficacy and safety of one of these systems, the EkoSonic Endovascular System (EKOS). The objective of this study was to evaluate the long-term efficacy and safety of EKOS in submassive PE. Methods: This single-center, retrospective study evaluated subjects ≥18 years old with submassive PE and baseline right ventricular to left ventricular (RV/LV) diameter ratio ≥1. The primary outcome evaluated change in RV/LV diameter ratio from baseline to first follow-up. The secondary outcomes evaluated need for further intervention after EKOS, major bleeding within 72 hours and 6 months, all-cause mortality at 6 months, and all-cause 30-day readmission rate. Results: Overall, 41 subjects received EKOS for submassive PE. Of the 26 subjects evaluated for the primary outcome, the RV/LV diameter ratio decreased by an average of 0.56 (P < 0.05). Of the 41 subjects evaluated for the secondary outcomes, 1 subject required pulmonary embolectomy after EKOS intervention, 1 major bleed occurred within 72 hours, 1 major bleed occurred within 6 months, 1 subject died within 6 months, and 3 subjects were readmitted within 30 days. Conclusions: Intervention with EKOS further reduced right heart strain and resulted in few complications compared with previous trials providing evidence that EKOS is effective and safe long-term for management of submassive PE. Use should be considered in patients with relative contraindications to systemic thrombolytic therapy.

Radiological Cardiothoracic Ratio as a Potential Predictor of Right Ventricular Enlargement in Patients with Suspected Pulmonary Embolism Due to COVID-19.

The aim of the study was to determine the usefulness of the radiological cardiothoracic ratio (CTR) as a predictor of right ventricular enlargement in patients with suspected pulmonary embolism during COVID-19. The study group consisted of 61 patients with confirmed COVID-19, suspected of pulmonary embolism based on physical examination and laboratory tests (age: 67.18 ± 12.47 years). Computed tomography angiography (CTA) of pulmonary arteries and chest radiograph in AP projection with cardiothoracic ratio assessment were performed in all patients. Right ventricular enlargement was diagnosed by the ratio of right ventricular to left ventricular (RV/LV) dimensions in pulmonary CTA with two cut-off points: ≥0.9 and ≥1.0. Heart silhouette enlargement was found when CTR on the chest radiograph in the projection AP > 0.55. The mean values of RV/LV and CTR in the studied group were 0.96 ± 0.23 and 0.57 ± 0.05, respectively. Pulmonary embolism was diagnosed in 45.9%. Right ventricular enlargement was documented in 44.3% or 29.5% depending on the adopted criterion RV/LV ≥ 0.9 or RV/LV ≥ 1.0. Heart silhouette enlargement was found in 60.6%. Patients with confirmed pulmonary embolism (PE+) had a significantly higher RV/LV ratio and CTR than patients with excluded pulmonary embolism (PE−) (RV/LV: PE+ 1.08 ± 0.24, PE− 0.82 ± 0.12; CTR: PE+ 0.60 ± 0.05, PE− 0.54 ± 0.04; p < 0.05). The correlation analysis showed a statistically significant positive correlation between the RV/LV ratio and CTR (r = 0.59, p < 0.05). Based on the ROC curves, CTR values were determined as the optimal cut-off points for the prediction of right ventricular enlargement (RV/LV ≥ 0.9 or RV/LV ≥ 1.0), being 0.54 and 0.55, respectively. The sensitivity, specificity, and accuracy of the CTR criterion >0.54 as a predictor of RV/LV ratio ≥0.9 were 0.412, 0.963, and 0.656, respectively, while those of the CTR criterion >0.55 as a predictor of RV/LV ratio ≥1.0 were 0.488, 0.833, and 0.590, respectively. In summary, in patients with suspected pulmonary embolism during COVID-19, the radiographic cardiothoracic ratio can be considered as a prognostic factor for right ventricular enlargement, especially as a negative predictor of right ventricular enlargement in the case of lower CTR values.

Acute Pulmonary Embolism Severity Assessment Evaluated with Dual Energy CT Perfusion Compared to Conventional CT Angiographic Measurements

The purpose of the study was to investigate whether Dual Energy CT (DECT) can be used as a diagnostic tool to assess the severity of acute pulmonary embolism (PE) by correlating parenchymal perfusion defect volume, obstruction score and right ventricular-to-left ventricular (RV/LV) diameter ratio using CT angiography (CTA) and DECT perfusion imaging. A total of 43 patients who underwent CTA and DECT perfusion imaging with clinical suspicion of acute PE were retrospectively included in the study. In total, 25 of these patients had acute PE findings on CTA. DECT assessed perfusion defect volume (PDvol) were automatically and semiautomatically quantified. Overall, two CTA methods for risk assessment in patients with acute PE were assessed: the RV/LV diameter ratio and the Modified Miller obstruction score. Automatic PDvol had a weak correlation (r = 0.47, p = 0.02) and semiautomatic PDvol (r = 0.68, p < 0.001) had a moderate correlation to obstruction score in patients with confirmed acute PE, while only semiautomatic PDvol (r = 0.43, p = 0.03) had a weak correlation with the RV/LV diameter ratio. Our data indicate that PDvol assessed by DECT software technique may be a helpful tool to assess the severity of acute PE when compared to obstruction score and RV/LV diameter ratio.

Short Duration Catheter-directed Thrombolysis for Acute Pulmonary Embolism Rapidly Improves Acute Cardiac Function

Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography. Retrospective analysis of prospectively collected data at a single-institution treating massive and submassive PE with catheter-directed thrombolysis (CDT). Internal review board approval was obtained. Descriptive statistical analysis was performed from the data set. Continuous covariates were presented in mean (SD) or median (IQR) and categorical covariates as number (percentage). For continuous variables, a paired t test was used to measure results against the baseline. P value less than 0.05 was defined as statistically significant. STATA® statistical software was used for analysis. From January of 2013 to December of 2016, 28 consecutive patients were treated for massive and submassive PE with CDT. All patients had evidence of right heart strain on echocardiogram, as evidence by a right ventricular to left ventricular (RV/LV) diameter ratio of >0.9. Of the 28 patients, 19 (68%) had hemodynamic derangement with either systolic blood pressure (SBP) less then 90 or tachycardia (HR>100). The mean RV/LV ratio before CDT was 1.18. After therapy, RV/LV ratio was reduced to 0.86 at 48hr (P<0.0001). In addition, mean right ventricular systolic pressure (RVSP) before CDT treatment was 53mm Hg, and after treatment, RVSP was reduced to 40mm Hg at 48-hr (P value=0.0001). There was complete resolution of hypotension in hemodynamically unstable patients (i.e., SBP <90) after CDT. Mean HR before therapy was 102. After 24hr of CDT, mean HR reduced to 84 (P<0.0001). From 2013 to 2016, there was a significant decrease in mean hospital length of stay from 8days to 4days (P=0.05). Mean t-PA dose used decreased, as well, from 2014 (21.7mg) to 2016 (14.9mg), but this was not statistically significant (P=0.13). There was no major bleeding complications or CDT-related death in any of the patients treated during the study period. CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right heart strain acutely. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvement in tachycardia and resolution of hypotension were seen within 24hr of CDT. Tissue plasminogen activator dosage decreased throughout the study period as a more restrictive approach to follow-up angiography was used without adverse safety or patient outcomes.

Predictors of Treatment Response Following Ultrasound-Facilitated Catheter-Directed Thrombolysis for Submassive and Massive Pulmonary Embolism: A SEATTLE II Substudy.

Little is known about which factors predict improvement in clinical and imaging parameters among patients undergoing catheter-directed thrombolysis for submassive or massive pulmonary embolism. The identification of such predictors may allow for more appropriate patient selection for ultrasound-facilitated catheter-directed thrombolysis. We conducted a retrospective cohort analysis of patients from the SEATTLE II trial (Prospective, Single-Arm, Multi-Center Trial of EkoSonic Endovascular System and Activase for Treatment of Acute Pulmonary Embolism) to identify clinical characteristics that independently predict pulmonary artery pressures, right ventricular-to-left ventricular (RV/LV) diameter ratio, and modified Miller angiographic index following ultrasound-assisted catheter-directed thrombolysis. Eligible patients had submassive or massive pulmonary embolism and an RV/LV diameter ratio ≥0.9 on chest computed tomography. Multivariable linear regression was used to identify independent clinical predictors of each outcome. One hundred fifty patients with massive (n=31) or submassive (n=119) pulmonary embolism were enrolled. Mean (±SD) baseline and postprocedure RV/LV diameter ratio, pulmonary artery systolic pressure, and modified Miller Score were 1.59 (±0.39) and 1.14 (±0.2), 51.45 (±16.0), and 37.47 (±11.9), and 23.0 (±5.7) and 15.7 (±5.9), respectively. The multivariable model adjusted R2 for absolute change in RV/LV ratio, pulmonary artery systolic pressure, modified Miller Score was 0.71, 0.57, and 0.43, respectively. After adjusting for age, gender, and baseline RV/LV ratio, pulmonary artery systolic pressure, and modified Miller Score, patients with higher body mass index, renal or hepatic dysfunction, active smoking, or a higher baseline heart rate showed less improvement. Patients with more life-threatening pulmonary embolism may derive the greatest benefit from ultrasound-assisted, catheter-directed thrombolysis.

Interstitial Features at Chest CT Enhance the Deleterious Effects of Emphysema in the COPDGene Cohort.

Purpose To determine if interstitial features at chest CT enhance the effect of emphysema on clinical disease severity in smokers without clinical pulmonary fibrosis. Materials and Methods In this retrospective cohort study, an objective CT analysis tool was used to measure interstitial features (reticular changes, honeycombing, centrilobular nodules, linear scar, nodular changes, subpleural lines, and ground-glass opacities) and emphysema in 8266 participants in a study of chronic obstructive pulmonary disease (COPD) called COPDGene (recruited between October 2006 and January 2011). Additive differences in patients with emphysema with interstitial features and in those without interstitial features were analyzed by using t tests, multivariable linear regression, and Kaplan-Meier analysis. Multivariable linear and Cox regression were used to determine if interstitial features modified the effect of continuously measured emphysema on clinical measures of disease severity and mortality. Results Compared with individuals with emphysema alone, those with emphysema and interstitial features had a higher percentage predicted forced expiratory volume in 1 second (absolute difference, 6.4%; P < .001), a lower percentage predicted diffusing capacity of lung for carbon monoxide (DLCO) (absolute difference, 7.4%; P = .034), a 0.019 higher right ventricular-to-left ventricular (RVLV) volume ratio (P = .029), a 43.2-m shorter 6-minute walk distance (6MWD) (P < .001), a 5.9-point higher St George's Respiratory Questionnaire (SGRQ) score (P < .001), and 82% higher mortality (P < .001). In addition, interstitial features modified the effect of emphysema on percentage predicted DLCO, RVLV volume ratio, 6WMD, SGRQ score, and mortality (P for interaction < .05 for all). Conclusion In smokers, the combined presence of interstitial features and emphysema was associated with worse clinical disease severity and higher mortality than was emphysema alone. In addition, interstitial features enhanced the deleterious effects of emphysema on clinical disease severity and mortality.

Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.

Right Ventricular Outflow Tract Reconstruction With a Polytetrafluoroethylene Monocusp Valve: A 20-Year Experience

In patients with tetralogy of Fallot (TOF), pulmonary atresia (PA), and other congenital right ventricular outflow tract (RVOT) malformations, polytetrafluoroethylene (PTFE) monocusp outflow tract patches (MOTP) relieve obstruction and provide pulmonary valve competence. The purpose of this study was to determine whether our PTFE-MOTP was an acceptable short- and mid-term remedy for patients with TOF or PA as assessed by freedom from severe pulmonary regurgitation and freedom from reoperation. From 1994-2014, 171 patients (mean age 1.5 ± 1.5 years; median 1.1 years) with TOF or PA underwent initial right ventricular outflow tract (RVOT) reconstruction with a PTFE-MOTP. Patients were studied intraoperatively and serially postoperatively using echocardiography and cardiac magnetic resonance imaging (CMR) to determine pulmonary valve dysfunction defined as a peak gradient >40mmHg or valve regurgitation>moderate. The mean follow-up duration was 10.9 ± 5.8 years (range: 1 month-20 years). There were 5 late deaths and 1 early death. There was a significant difference between the preoperative and postoperative peak RVOT gradients (74.0 vs 25.2mmHg). Of the 171 patients, 25 were lost to follow-up, and 42 have required replacement of their monocusp valves 10.1 ± 5.0 years (range: 5 months-19 years) after original monocusp insertion. At 10-year follow-up, severe pulmonary regurgitation was seen in less than 25% of patients, and severe pulmonary stenosis was seen in less than 10% of patients. Since 2007, CMR was used in 44 patients to characterize cardiac function in patients under consideration for PTFE-MOTP replacement. The average right ventricular-to-left ventricular (RV/LV) ratio on CMR was 1.7 ± 0.5 in these patients. CMR also showed that RV ejection fraction (52 ± 9%) and left ventricular ejection fraction (58 ± 7%) were both preserved in most patients. The PTFE-MOTP is an excellent short-term and mid-term option for initial RVOT reconstruction, particularly in children with TOF with nonsalvageable pulmonary valve or PA-ventricular septal defect.

Automated axial right ventricle to left ventricle diameter ratio computation in computed tomography pulmonary angiography.

Background and PurposeRight Ventricular to Left Ventricular (RV/LV) diameter ratio has been shown to be a prognostic biomarker for patients suffering from acute Pulmonary Embolism (PE). While Computed Tomography Pulmonary Angiography (CTPA) images used to confirm a clinical suspicion of PE do include information of the heart, a numerical RV/LV diameter ratio is not universally reported, likely because of lack in training, inter-reader variability in the measurements, and additional effort by the radiologist. This study designs and validates a completely automated Computer Aided Detection (CAD) system to compute the axial RV/LV diameter ratio from CTPA images so that the RV/LV diameter ratio can be a more objective metric that is consistently reported in patients for whom CTPA diagnoses PE.Materials and MethodsThe CAD system was designed specifically for RV/LV measurements. The system was tested in 198 consecutive CTPA patients with acute PE. Its accuracy was evaluated using reference standard RV/LV radiologist measurements and its prognostic value was established for 30-day PE-specific mortality and a composite outcome of 30-day PE-specific mortality or the need for intensive therapies. The study was Institutional Review Board (IRB) approved and HIPAA compliant.ResultsThe CAD system analyzed correctly 92.4% (183/198) of CTPA studies. The mean difference between automated and manually computed axial RV/LV ratios was 0.03±0.22. The correlation between the RV/LV diameter ratio obtained by the CAD system and that obtained by the radiologist was high (r=0.81). Compared to the radiologist, the CAD system equally achieved high accuracy for the composite outcome, with areas under the receiver operating characteristic curves of 0.75 vs. 0.78. Similar results were found for 30-days PE-specific mortality, with areas under the curve of 0.72 vs. 0.75.ConclusionsAn automated CAD system for determining the CT derived RV/LV diameter ratio in patients with acute PE has high accuracy when compared to manual measurements and similar prognostic significance for two clinical outcomes.

The role of CT pulmonary angiography in the diagnosis and prognosis of pulmonary embolism and correlation with blood gas values

To analyze the value of CT pulmonary angiography (CTPA) in assessing the severity of pulmonary embolism (PE), and to investigate the correlations of the parameters from CTPA with blood gas values. Forty-four PE patients were classified into 19 critical and 25 non-critical patients, and 37 subjects without PE were defined as control group. Right ventricular (RV) and left ventricular (LV) maximal short axis, RV to LV (RV/LV), superior vena cava and pulmonary artery diameter, obstruction index, leftward bowing of interventricular septum, reflux of contrast medium into inferior vena cava were compared among the 3 groups. The correlations of these parameters with blood gas values were investigated. There were significant differences in RV, LV, RV/LV, superior vena cava and pulmonary artery diameter, leftward bowing of interventricular septum, reflux of contrast medium into inferior vena cava when compared among 3 groups (P < 0.05). However, significant differences were detected in RV, LV and RV/LV between critical [(53 ± 8) mm, (35 ± 6) mm, 1.56 ± 0.50] and non-critical group [(45 ± 7) mm, (43 ± 9) mm, 1.09 ± 0.31] (RV: t = 3.44, P < 0.05; LV: t = 3.08, P < 0.05; RV/LV: t = 4.62, P < 0.05), critical group and group without PE [(40 ± 7) mm, (43 ± 9) mm, 0.96 ± 0.23] (RV: t = 5.76, P < 0.05; LV: t = 3.40, P < 0.05; RV/LV: t = 6.33, P < 0.05). Superior vena cava diameter and pulmonary artery diameter were significantly different between critical group [(24 ± 4) mm, (33 ± 4) mm] and group without PE [(21 ± 4) mm, (29 ± 4) mm] (t = 2.80, P < 0.05; t = 3.98, P < 0.05). Pulmonary artery diameter in non-critical group (31 ± 5) mm was significantly different from group without PE (t = 2.59, P = 0.03). Reflux of contrast medium into inferior vena cava showed significant difference between critical group and group without PE (χ(2) = 5.54, P = 0.02). There was significant difference in obstruction index between critical (76 ± 24)% and non-critical group (52 ± 34)% (t = -2.75, P = 0.01). Obstruction index and RV/LV were negatively correlated with PaO(2) (r = -0.525, -0.502), while positively correlated with P((A-a))O(2) (r = 0.753, 0.630). Blood gas values differed significantly between above and below the 60%, 70% and 80% cutoff values of obstruction index. Superior vena cava and pulmonary artery diameter, reflux of contrast medium into inferior vena cava can be used as indirect evidence in the diagnosis of PE, while obstruction index, RV, LV, RV/LV and leftward bowing of interventricular septum can be applied as indicators of severity of PE. The severity of the obstruction index and RV/LV assessed using CTPA are significantly correlated to the blood gas values.

The Variability in Prognostic Values of Right Ventricular-to-Left Ventricular Diameter Ratios Derived From Different Measurement Methods on Computed Tomography Pulmonary Angiography

To evaluate variability in right ventricular-to-left ventricular (RV/LV) diameter ratios introduced by differences in measurement methods and the subsequent influence on the accuracy of predicting outcomes for patients with acute pulmonary embolism (PE). For 200 consecutive computed tomography pulmonary angiograms positive for acute PE, RV/LV diameter ratios were retrospectively measured using 3 different 4-chamber reformations and from axial images alone. The first 4-chamber reformation method (4ch-1) was a single oblique technique using LV morphology landmarks; the other 2 methods (4ch-2 and 4ch-3) were double oblique techniques that created an intermediate short-axis image to identify the maximum RV diameter but with different approaches to reach short-axis images. Interobserver variability was measured using 30 cases. Receiver-operating characteristic analysis compared the accuracy of predicting outcomes among the 4 measurements for PE-related death, and for death or the need for intensive therapies (composite outcome). The difference in median RV/LV diameter ratios was insignificant among 4ch-2 (1.01), 4ch-3 (1.02), and axial (1.03) datasets, whereas that from 4ch-1 (0.93) was significantly lower (P<0.001). Correlation between observers was excellent for all 4 datasets (r=0.881 to 0.925). Compared with 4ch-1, the other 3 datasets equally achieved higher accuracy in predicting PE-related 30-day mortality (area under curve: 0.55 vs. 0.69 to 0.73, P=0.007 to 0.019) and a composite outcome (area under curve: 0.65 vs. 0.77 to 0.78, P=0.003 to 0.010). Double oblique 4-chamber reformation methods that use intermediate short-axis images to optimize RV size predict outcomes better in patients with acute PE than do single oblique methods using only LV landmarks; however, their accuracy is not superior to that from measurements based on axial images.

Axial and Reformatted Four-Chamber Right Ventricle–to–Left Ventricle Diameter Ratios on Pulmonary CT Angiography as Predictors of Death After Acute Pulmonary Embolism

The purpose of this article is to retrospectively compare right ventricular-to-left ventricular (RV/LV) diameter ratios measured on the standard axial view versus the reformatted four-chamber view as predictors of mortality after acute pulmonary embolism (PE). Six hundred seventy-four consecutive patients (mean age, 58 years; 372 women) with a diagnosis of acute PE on pulmonary CT angiography were considered. The axial and reformatted four-chamber RV/LV diameter ratios were compared as predictors of 30-day all-cause and PE-related mortality. Ninety-seven patients (14%) died within 30 days; 39 deaths were PE related. There was no significant difference in the univariate hazard ratios (HRs) of axial and four-chamber RV/LV diameter ratios greater than 0.9 for both all-cause (HR, 2.13 [95% CI, 1.29-3.51] vs HR, 1.95 [95% CI, 1.22-3.14]; p = 0.74) and PE-related (HR, 19.6 [95% CI, 2.70-143] vs HR, 21.8 [95% CI, 2.99-158]; p = 1.0) mortality. Axial and four-chamber multivariate HRs accounting for potential confounders such as age and cancer were also similar for all-cause (HR, 1.79 [95% CI, 1.07-2.99] vs HR, 1.54 [95% CI, 0.95-2.49]; p = 0.62) and PE-related (HR, 16.3 [95% CI, 2.22-119] vs HR, 17.7 [95% CI, 2.43-130]; p = 1.0) mortality. There was no significant difference in sensitivity, specificity, negative predictive value, or positive predictive value. Axial and four-chamber measurements were well correlated (correlation coefficient, 0.857), and there was no significant difference in overall accuracy for predicting all-cause (area under the curve [AUC], 0.582 vs 0.577; p = 0.72) and PE-related (AUC, 0.743 vs 0.744; p = 1.0) mortality. The axial RV/LV diameter ratio is no less accurate than the reformatted four-chamber RV/LV diameter ratio for predicting 30-day mortality after PE.

Dual-Energy CT for Assessment of the Severity of Acute Pulmonary Embolism: Pulmonary Perfusion Defect Score Compared With CT Angiographic Obstruction Score and Right Ventricular/Left Ventricular Diameter Ratio

The purpose of this study was to prospectively evaluate the usefulness of scoring perfusion defects on perfusion images at dual-energy CT for assessment of the severity of pulmonary embolism. Thirty patients (13 men, 17 women; mean age, 55 +/- 15 [SD] years; range, 26-81 years) with pulmonary thromboembolism underwent dual-source CT at two voltages (140 and 80 kV). The weighted average image of two acquisitions was used for CT angiograms, and a color-coded iodine image was used for perfusion images. Two thoracic radiologists with 15 and 6 years of clinical experience independently assigned perfusion defect scores to perfusion images and both a CT angiographic (CTA) obstruction score and right ventricular-to-left ventricular (RV/LV) diameter ratio to CT angiograms. The CTA obstruction score was based on the Qanadli method. The perfusion defect score was defined as Sigma (n . d) / 40 x 100, where n is the number of segments and d is the degree of perfusion from 0 to 2. Correlations between perfusion defect score, CTA obstruction score, and RV/LV diameter ratio were evaluated. Agreement between perfusion defect score and CTA score was assessed per patient and per segment. Interobserver agreement regarding perfusion defect and CTA obstruction scores was analyzed. Perfusion defect and CTA obstruction scores had good correlation with RV/LV diameter ratio (r = 0.69, r = 0.66; all p < 0.001). Per patient, correlation between perfusion defect score and CTA obstruction score also was good (reader 1, r = 0.87; reader 2, r = 0.85; all p < 0.001). Per segment, moderate agreement was found between perfusion defect score and CTA obstruction score (reader 1, kappa = 0.56; reader 2, kappa = 0.51; all p < 0.05). Both readers were in strong agreement on perfusion defect score and CTA obstruction score. The proposed perfusion defect score had good correlation with RV/LV diameter ratio and CTA obstruction score. Therefore, acquisition of perfusion images at dual-energy CT may be helpful for assessing the severity of acute pulmonary embolism.

CT Findings of Acute Pulmonary Thromboembolism as a Predictor of the Response to Anticoagulant Therapy

Purpose: To determine the CT findings of an acute pulmonary thromboembolism for the prediction of response to anticoagulant therapy. Materials and Methods: Forty-eight patients diagnosed with a pulmonary embolism underwent anticoagulant therapy, and underwent pre- and post-treatment CT scans, were selected to be part of the study. Pre-treatment CT scans were retrospectively reviewed for the number and degree of emboli, right ventricular to left ventricular (RV/LV) diameter ratio, pulmonary arterial to aorta (PA/aorta) diameter ratio, ventricular septal bowing, consolidation, mosaic perfusion, and pleural effusion. The response to anticoagulant therapy was assessed by a change in embolic burden on pre-and post-treatment CT scans. The 48 patients were divided into two groups: good responder and poor responder. The pre-treatment CT findings were compared by group to determine if there were any differences in the CT findings. Results: Thirty patients were categorized as good responders (62.5%) and eighteen patients as poor responders (37.5%). A pleura-based wedge-shaped consolidation was observed in 9 of 18 cases (50%) from the poor responder group and one of 30 (3%) cases from the good responder group. The comparison of the finding by group was found to be significantly different (p

Total correction of tetralogy of fallot at age 40 years and older: Long-term follow-up

Whether total surgical correction of tetralogy of Fallot in adults aged 40 years old or older has acceptable operative risk and gratifying long-term results is unknown. The Mayo Clinic experience (June 1960 to May 1982) with 30 patients 40 to 60 years old (mean 47) who had total surgical correction of tetralogy of Fallot was reviewed. Preoperatively, 4 patients (13%) were in functional class I, 9 (30%) in class II and 17 (57%) in classes III and IV. Eight patients (27%) had had preoperative complications: five had a cerebrovascular accident and three had infective endocarditis. Only 11 patients (37%) had had palliative surgery 16 to 34 years (mean 22) before total surgical correction. Total surgical correction was successful in all patients. Right ventricular to left ventricular (RV/LV) pressure ratio of 0.65 or less was achieved in 28 (93%) of the 30 patients. One patient died of ventricular fibrillation (RV/LV ratio = 0.8) 2 days postoperatively, one had complete heart block and one had a cerebrovascular accident 7 days after operation. At follow-up of 5 to 266 months (mean 110), there were seven late deaths: two sudden at 5 and 21 years, respectively, after operation, one from myocardial infarction at 11 years, one from cerebrovascular accident at 11 years, one from congestive heart failure (RV/LV ratio = 1.0) at 8 years and two from noncardiac causes. Of the 22 patients who survived, 16 are in class I, 5 are in class II and 1 is in class III.(ABSTRACT TRUNCATED AT 250 WORDS)

Late results after repair of tetralogy of Fallot

Three hundred eleven patients up to 17 years of age underwent repair of tetralogy of Fallot from 1964 through 1970. Age of early death group versus early survivor group was 6.1 versus 7.5 years (p = 0.03), and the right ventricular–to–left ventricular (RVILV) pressure ratio was higher for the early death group—0.663 versus 0.569 (p < 0.01). Use of an outflow tract patch was associated with only a minimally higher early mortality rate (p = 0.07). Of early survivors, late results were ideal in 80 per cent, fair in 10 per cent, and poor in 3 per cent; the late mortality rate was 4 per cent. Five per cent had residual hemodynamic defects. The mean cardiothoracic (CT) ratio was 0.485 for the group with ideal results and 0.567 for those with poor results. The RV/LV pressure ratio after repair was considerably higher in the group with poor results (0.74 versus 0.56). These studies give support for (1) the need to achieve as complete a repair of pulmonary stenosis as possible, even if pulmonary insufficiency results and an outflow tract patch is required, and (2) continued avoidance of the insertion of a substitute pulmonary valve during repair of tetralogy in the typical patient until the long-term fate of such valves is known.