Symptomatic Pulmonary Embolism In Patients Research Articles

Usefulness of cardiopulmonary exercise test to detect exercise pulmonary hypertension in the post pulmonary embolim follow-up

Abstract Functional impairment is largely reported after symptomatic pulmonary embolism (PE). Chronic thromboembolic pulmonary disease (CTED) refers to the presence of chronic thrombotic pulmonary vascular occlusion in the absence of pulmonary hypertension (PH) at rest but with incipient vasculopathy responsible for exercise limitation. Exercise haemodynamic studies have emerged to detect an abnormal response suggesting an established vasculopathy or an abnormal left ventricular filling pressure. We hypothesized that exercise intolerance due to an abnormal haemodynamic response during exercise might be unmasked by the parameters exhibited at the cardiopulmonary exercise test (CPET) in diagnostic workup after PE in symptomatic patients. Our aim was to correlate the values reached in the CPET pattern with haemodynamic response during exercise right heart catheterization (RHC) in patients with CTED suspicion. Methods We selected symptomatic patients with confirmed perfusion defects in lung scintigraphy despite optimal anticoagulant therapy for a minimum of 3 months after a PE with normal lung function tests. Left heart disease and significant PH were ruled out with RHC (inclusion criteria implied mean pulmonary arterial pressure (mPAP) < 25 mmHg and pulmonary vascular resistance (PVR) < 3 WU and pulmonary arterial wedge pressure (PAWP) ≤15 mmHg). Exercise RHC was performed sequentially 24 hours after CPET. The exercise protocol was the same for both tests. Pulmonary pressure and cardiac output (CO) were collected at each exercise leel. Exercise PH (ex-PH) was considered when mPAP/CO slope >3 mmHg·L−1·min−1. We made a subanalysis according to the new PH criteria (mPAP >20mmHg & PVR > 2 WU at rest). Results 39 patients (median age 52.7 ± 15.7 years, 36% females) were included. 21 (53.8%) showed abnormal haemodynamic behaviour, 6(15.4%) of them due to abnormal PWAP/CO slope. Baseline characteristics are summarized in Table 1. Patients with abnormal exercise response showed worse ventilatory efficiency at exercise: 1) reduced partial end-tidal of carbon dioxide (PetCO2) at the anaerobic threshold (AT) (32.0 Vs 36.4, p=0.001), 2) a steeper VE/CO2 slope (35.6 Vs 30.9, p=0.009) and 3) a higher ventilatory equivalent for CO2 at the AT (35.5 Vs 31.6, p=0.004) compared to the group with normal hemodynamic behaviour. Oxygen consumption at the AT and peak oxygen consumption were slightly decreased without statistically significant differences between groups.Of the global cohort, 11 patients reached new resting PH criteria, and 92% of them showed ex-PH. Ventilatory efficiency showed differences in the subgroup with normal resting hemodynamic values, especially lower PetCO2 at the AT (31.8 Vs 35.0, p=0.008) (Figure 2). Conclusion In the context of persistent dyspnoea after PE, ventilatory inefficiency is a sign of exercise pulmonary hypertension, and CPET could identify patients with abnormal exercise response despite normal hemodynamic values at rest.

Cost-effectiveness of early placement of vena cava filters to prevent symptomatic pulmonary embolism in patients with contraindications to prophylactic anticoagulant.

Vena cava filters have been used as a primary means to prevent symptomatic pulmonary embolism (PE) in trauma patients who cannot be anticoagulated after severe injury, but the economic implications for this practice remain unclear. Using a healthcare system perspective to analyze the a priori primary outcome of the da Vinci trial, we report the cost-effectiveness of using vena cava filters as a primary means to prevent PE in patients who have contraindications to prophylactic anticoagulation after major trauma. Of the 240 patients enrolled, complete, prospectively collected, hospital cost data during the entire hospital stay - including costs for the filter, medical/nursing/allied health staff, medical supplies, pathology tests, and radiological imaging - were available in 223 patients (93%). Patients allocated to the filter group (n = 114) were associated with a reduced risk of PE (0.9%) compared to those in the control group (n = 109, 5.5%; p = 0.048); and the filter's benefit was more pronounced among those who could not be anticoagulated within 7 days (filter: 0% vs control: 16%, Bonferroni-corrected p = 0.02). Overall, the cost needed to prevent one PE was high (AUD $379,760), but among those who could not be anticoagulated within 7 days, the costs to prevent one PE (AUD $36,156; ~ USD $26,032) and gain one quality-adjusted life-year (AUD $30,903; ~ USD $22,250) were substantially lower. The cost of using a vena cava filter to prevent PE for those who have contraindications to prophylactic anticoagulation within 3 days of injury is prohibitive, unless such contraindications remain for longer than 7 days. (Australian New Zealand Clinical Trials Registry no.: ACTRN12614000963628).

The Timing of Symptomatic Pulmonary Embolism in Patients With Nonwarfarin Anticoagulants Following Elective Primary Total Joint Arthroplasty

BackgroundThe purpose of this study is to investigate the incidence and timing of postoperative, symptomatic pulmonary embolism (PE) in patients receiving nonwarfarin treatment following primary total joint arthroplasty (TJA), to clarify the appropriate duration of postoperative VTE prophylaxis. MethodsWe retrospectively reviewed the medical records of 11,148 patients who underwent primary TJA, including total knee arthroplasty and total hip arthroplasty at our institution between January 2012 and March 2019. The median postoperative day of diagnosis of symptomatic PE and the interquartile range for day of diagnosis were determined. Multivariate Cox proportional hazards modeling was used to test the difference of timing for PE based on demographics and comorbidities. ResultsThe overall 90-day rate of symptomatic PE was 0.71%. The median day of diagnosis for symptomatic PE was 3 days postoperatively (interquartile range, 2-7 days). Factors showed statistical significance on multivariate analysis in association with earlier timing of PE occurrence in patients with atrial fibrillation, diabetes mellitus, coronary heart disease, and history of stroke. ConclusionThe vast majority of symptomatic PE occurs in the early postoperative period after TJA, and atrial fibrillation, diabetes mellitus, coronary heart disease, and history of stroke were independent factors affecting the timing of symptomatic PE.

Coagulation factor IV is an indicator of symptomatic pulmonary embolism in patients with primary lung cancer.

Coagulation factor IV, also known as serum ionised calcium (SIC), participates in coagulative process and tends to elevate in patients with primary lung cancer. It may be an indicator of symptomatic pulmonary embolism (PE) due to primary lung cancer (LC). A total of 388 patients who underwent CTPA and/or radionuclide ventilation perfusion scanning due to PE-suspected symptoms were stratified into LCPE (lung cancer and PE) group (n=95), PE group (n=99), LC group (n=98) and control group (n=96). At admission, the level of SIC and STC (serum total calcium) was compared among four groups. At discharge, the level change of SIC and STC from admission to discharge was compared among four groups. The coefficients analysis between SIC as well as STC and the possibility of PE were performed. The SIC of LCPE group was the highest among four groups at admission (P<0.001). The level change of SIC from admission to discharge in LCPE group was the highest among four groups (P=0.001). A ROC curve analysis demonstrated that the sensitivity and specificity of SIC for a diagnosis of PE among LC patients were 71.9% and 86.0%, respectively. The area under curve (AUC) was 0.781. Along with the increase of 0.1mmol/L in SIC level, the risk ratio for a PE was 2.165 (1.537-2.849) (P<0.001). Serum ionised calcium may be an indicator of pulmonary embolism in patients with primary lung cancer.

Challenges in the diagnosis of sub-segmental pulmonary embolism in symptomatic patients: a case report.

Challenges in the diagnosis of sub-segmental pulmonary embolism in symptomatic patients: a case report.

Does intermittent pneumatic compression increase the risk of pulmonary embolism in deep venous thrombosis after joint surgery?

The present study aimed to identify the incidence and risk factors of symptomatic pulmonary embolism and evaluate the safety of early intermittent pneumatic compression application in patients with deep venous thrombosis (DVT) after joint surgery. A total of 144 patients with DVT undergoing joint surgery were divided into two groups according to the appearance of symptomatic pulmonary embolism. Venography and computed tomographic pulmonary angiography were utilized as the assessment methods. The total incidence of symptomatic pulmonary embolism was 0.39% after joint surgery. However, the prevalence increased to 3.5% when computed in patients with DVT. Patients with symptomatic pulmonary embolism were older than those without symptomatic pulmonary embolism (69 ± 4 versus 61 ± 15 years, P = 0.04). The occurrence rate of symptomatic pulmonary embolism in patients with diabetes mellitus was much higher than that in the patients without diabetes mellitus (40.0% versus 8.6%, respectively, P = 0.02). The prevalence of symptomatic pulmonary embolism after joint surgery in patients with DVT was not distinctive. Increased age and diabetes mellitus put patients with DVT at risk of suffering symptomatic pulmonary embolism after joint surgery. In addition, early postoperative application of intermittent pneumatic compression was safe in these patients.

Superior vena cava (SVC) filters placed over central lines – analysis of line trapping and difficulties with line retrieval: an in-vitro experimental study

Placement of superior vena cava (SVC) filters has been shown to be both safe and effective in preventing symptomatic pulmonary embolism in patients with upper extremity deep venous thrombosis that have contraindications to anticoagulation therapy. In many patients, existing central lines pose a challenge to SVC filter placement due to the theoretical risk of line displacement and/or entrapment. To assess the risk of catheter entrapment by filter legs during SVC filter deployment and the risk of subsequent filter migration during catheter removal. A model was created by placing a 22 mm vascular graft inside a plastic tube and submerged in a warm saline bath. Five types of filters were deployed under fluoroscopic guidance over different types of central lines of varying calibers (5-14 Fr). Each filter was deployed five times over each type of central line. The positioning of the legs of the filters in relationship to the central lines was studied by fluoroscopic and direct inspection. The lines were then removed under fluoroscopic guidance noting any line trapping, migration, and/or tilting of the filters. Movement of the lines during filter expansion was commonly seen after deployment of all filters with varying frequencies. During line removal slight resistance was encountered with the Celect filter (10%) and the Option filter (5%), while significant resistance was only encountered when using the OptEase filter (20%). Filter migration was only observed when the OptEase filter was deployed over large (>10 Fr) caliber lines (10%). When SVC filters are placed over existing central lines, the risk of catheter entrapment is very low in this in-vitro model. Filter migration during line retrieval was only observed when the OptEase filter was placed over >10 Fr caliber lines.

Effectiveness of MR angiography for the primary diagnosis of acute pulmonary embolism: clinical outcomes at 3 months and 1 year.

To determine the effectiveness of MR angiography for pulmonary embolism (MRA-PE) in symptomatic patients. We retrospectively reviewed all patients whom were evaluated for possible pulmonary embolism (PE) using MRA-PE. A 3-month and 1-year from MRA-PE electronic medical record (EMR) review was performed. Evidence for venous thromboembolism (VTE) (or death from PE) within the year of follow-up was the outcome surrogate for this study. There were 190 MRA-PE exams performed with 97.4% (185/190) of diagnostic quality. There were 148 patients (120 F: 28 M) that had both a diagnostic MRA-PE exam and 1 complete year of EMR follow-up. There were 167 patients (137 F: 30 M) with 3 months or greater follow-up. We found 83% (139/167) and 81% (120/148) MRA-PE exams negative for PE at 3 months and 1 year, respectively. Positive exams for PE were seen in 14% (23/167). During the 1-year follow-up period, five patients (false negative) were diagnosed with DVT (5/148 = 3.4 %), and one of these patients also experienced a non-life-threatening PE. The negative predictive value (NPV) for MRA-PE was 97% (92-99; 95% CI) at 3 months and 96% (90-98; 95% CI) with 1 year of follow-up. The NPV of MRA-PE, when used for the primary diagnosis of pulmonary embolism in symptomatic patients, were found to be similar to the published values for CTA-PE. In addition, the technical success rate and safety of MRA-PE were excellent.

Factors affecting the occurrence of pulmonary embolism after spinal surgery: data from the national administrative database in Japan

Despite potentially devastating consequences, pulmonary embolism (PE) in patients undergoing spinal surgery remains poorly understood. To the best of our knowledge, few large studies have examined the prevalence and risk factors of PE after spinal surgery. To investigate the prevalence of symptomatic PE in patients undergoing elective spinal surgery and to identify clinical variables associated with the occurrence of postoperative PE. A retrospective analysis of data abstracted from the diagnosis procedure combination (DPC) database, a nationally representative database in Japan. We included all patients with a diagnosis of spinal canal stenosis, disc herniation, spondylosis, spondylolisthesis, trauma, metastatic tumor, or infection who underwent spinal surgery between July 1 and December 31 of 2007 and 2008, respectively. The primary end point was defined as the occurrence of postoperative PE during hospitalization. The secondary end point was in-hospital death after postoperative PE. We analyzed the association between the occurrence of postoperative PE and clinical variables recorded in the DPC database, including age, sex, comorbidities, location of surgery, primary diagnosis, anterior/posterior approach, use of instrumentation, and duration of anesthesia. A total of 47,743 patients were identified. Of these, 50 (0.10%) developed PE and four died as a result of PE. Logistic regression analyses revealed that occurrence of PE was associated with older age (70 years or older; odds ratio [OR], 3.15; 95% confidence interval [CI], 1.15-8.69; p=.026) and longer anesthesia time (more than 360 minutes; OR, 2.19; 95% CI, 0.88-5.44; p=.092). Patients with trauma were significantly more likely to have a PE than those with spinal canal stenosis (0.27% vs. 0.09%; OR, 2.86; 95% CI, 1.14-7.18; p=.026). This retrospective analysis of a nationally representative database identified older age, longer anesthesia time, and spinal trauma as risk factors for increased incidence of postoperative PE. Surgeons should be aware of the increased risk of postoperative PE in these subgroups of patients.

Transvenous Extraction of Pacemaker Leads in Infective Endocarditis With Vegetations ≥20 mm: Our Experience

According to published evidence, treatment of infective endocarditis (IE) associated with cardiovascular implantable electronic devices (CIEDs) should include complete removal of the system. Several publications have shown that transvenous removal is an effective and safe nonthoracotomy approach in patients with large vegetations, but experiences with vegetations larger than 20 mm have rarely been reported. Our aim was to describe our experience in percutaneous removal of CIEDs in patients with IE with large vegetations. The data were collected retrospectively and analyzed prospectively. We evaluated in-hospital morbidity and mortality related to percutaneous removal of vegetations ≥20 mm. This included 8 cases with a follow-up period of 20 months. We removed 100% of leads in the study population. Two patients experienced minor complications. No patient experienced subclavian vein laceration, hemothorax and lead fracture, or severe tricuspid regurgitation. After the removal procedure, 2 patients had symptoms compatible with pulmonary embolism. Both in-hospital mortality and mortality at follow-up were zero. Transvenous extraction of pacing leads with larger vegetations is a feasible technique. There was a tendency toward symptomatic pulmonary embolism in patients with vegetations larger than 20 mm; however, morbidity and mortality were not influenced. We agree with the consensus that this procedure is highly useful and that the selection of the removal techniques will depend not only on the size of vegetation but also on prior cardiopulmonary conditions, concomitant cardiac surgery, atrial septal defect with risk of paradoxical embolism, center experience, and the possibility of complete removal of the device.

AAOS Guidelines for the Prevention of Symptomatic Pulmonary Embolism After Total Hip and Total Knee Arthroplasty: Advantages and Disadvantages

The American Academy of Orthopedic Surgeons has published a clinical guideline for the prevention of symptomatic pulmonary embolism in patients undergoing total hip and total knee arthroplasty. This guideline includes recommendations from a consensus process and a review and analysis of 42 publications since 1996. The end points for analysis were symptomatic and fatal pulmonary embolism rates, total death rates, and major bleeding complications. The guideline recommends preoperative risk stratification of all patients for “standard” and “high” risks of both pulmonary embolism and major bleeding complications. The use of regional anesthesia, mechanical prophylaxis, rapid mobilization, and patient education were consensus recommendations. The choice of a specific medication postoperatively by the surgeon should be based on an individual risk–benefit analysis of pulmonary embolism and major bleeding complications. The advantages of this guideline include a greater concern for bleeding and other local wound complications that could affect overall patient outcome, and the ability of the surgeon to treat each patient as an individual. The disadvantages of this guideline include placing hip and knee arthroplasty patients into a single group, the lower levels of evidence for the recommendations, and the relative lack of acceptance by other specialty groups and governmental agencies.

Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty

This clinical practice guideline is based on a systematic review of published studies on the management of adult patients undergoing total hip replacement (THR) or total knee replacement (TKR) aimed specifically at preventing symptomatic pulmonary embolism (PE). The guideline emphasizes the need to assess the patient's risk for both PE and postoperative bleeding. Mechanical prophylaxis and early mobilization are recommended for all patients. Chemoprophylactic agents were evaluated using a systematic literature review. Forty-two studies met eligibility criteria, of which 23 included patients who had TKR and 25 included patients who had THR. The following statements summarize the recommendations for chemoprophylaxis: Patients at standard risk of both PE and major bleeding should be considered for aspirin, low-molecular-weight heparin (LMWH), synthetic pentasaccharides, or warfarin with an international normalized ratio (INR) goal of < or =2.0. Patients at elevated (above standard) risk of PE and at standard risk of major bleeding should be considered for LMWH, synthetic pentasaccharides, or warfarin with an INR goal of < or =2.0. Patients at standard risk of PE and at elevated (above standard) risk of major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none. Patients at elevated (above standard) risk of both PE and major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none.

Apport de la clinique : faut-il utiliser un score ?

The determination of the clinical pretest probability using clinical prediction models is an important step in the assessment of patients with suspected pulmonary embolism (PE). It helps establish which test or sequence of tests can effectively corroborate or safely rule out PE. For example, it has been demonstrated that it is safe to withhold anticoagulant therapy in patients with negative d-dimer results and low pretest probability at initial presentation. Clinical probability will also increase the diagnostic yield of ventilation perfusion lung scan. Compared with clinical gestalt, clinical prediction rules provide a standardized and more reproducible estimate of a patient's probability of having a PE. Clinical prediction models combine aspects of the history and physical examination to categorize a patient's probability of having a disease. The models classify patients as having a low, moderate, or high likelihood of having PE. Clinical prediction models have been validated and are well established for the diagnosis of PE in symptomatic patients. They allow all physicians, whatever their expertise, to reliably determine the clinical pretest probability of PE, and thus safely manage their patients using diagnostic and therapeutic algorithms.

Predictors of mortality following symptomatic pulmonary embolism in patients undergoing noncardiac surgery

To determine 30-day mortality and predictors of mortality following perioperative pulmonary embolism (PE). We searched both the Mayo Clinic electronic medical records and Autopsy Registry, between January 1, 1998 and December 31, 2001, for patients who developed PE within 30 days after noncardiac surgery performed under general or neuraxial anesthesia. Medical records of all identified patients were reviewed using standardized data collection forms. The association between risk factors for PE and 30-day post-PE mortality was assessed using t tests, exact binomial tests, and logistic regression. We identified 158 patients with probable or definite perioperative PE. The overall 30-day mortality from the day of PE was 25.3%, i.e., 40 patients died. Hypotension requiring treatment, need for mechanical ventilation, and intensive care unit admission were the prominent univariate predictors of 30-day mortality (all P <or= 0.001). Other significant factors were exact bi normal tests, and higher ASA physical status (P = 0.002), longer surgical time (P = 0.030), recent central vein cannulation (P = 0.021) and intraoperative use of either blood transfusions or other blood products (P = 0.010). Using multivariable analysis, hemodynamic instability was found to be the dominant independent risk factor associated with mortality. Perioperative PE is associated with a high 30-day mortality. Patients who experience hemodynamic instability and require vasoactive treatment at presentation of PE have extremely low survival rates; therefore, for these patients the most aggressive therapeutic modalities should be considered.

Helical computed tomography and magnet resonance imaging: diagnosis of pulmonary embolism in symptomatic patients

Helical computed tomography and magnet resonance imaging: diagnosis of pulmonary embolism in symptomatic patients

Helical computed tomography and magnet resonance imaging: diagnosis of pulmonary embolism in symptomatic patients.

The diagnosis of pulmonary embolism is challenging because lung scanning is nondiagnostic in most patients and because pulmonary angiography is invasive. Advancements in computed tomography and magnetic resonance imaging have enabled visualization of pulmonary emboli. Studies using each of these modalities have demonstrated high sensitivity for lobar and segmental emboli and lower sensitivity for subsegmental emboli. A recent study of a management approach using spiral computed tomography combined with testing for deep vein thrombosis using compression ultrasonography was found to have high clinical validity. A number of different magnetic resonance imaging techniques have been used to identify pulmonary emboli, and no single technique has been shown to be superior. Further studies are needed to delineate the role of magnetic resonance imaging in the management of patients with suspected pulmonary embolism.

A Comparative Study of Two Rapid D-dimer Tests for the Exclusion of Pulmonary Embolism in Symptomatic Patients

A Comparative Study of Two Rapid D-dimer Tests for the Exclusion of Pulmonary Embolism in Symptomatic Patients -

2 Diagnostic management of venous thromboembolism

The accuracy of diagnostic methods for the diagnosis of deep vein thrombosis and pulmonary embolism in symptomatic patients is critically reviewed. In addition, the safety of withholding anticoagulant therapy from patients with suspected deep vein thrombosis or pulmonary embolism in whom the qualified diagnostic strategy was normal is evaluated by determining the frequency of venous thromboembolic complications during 3 months of follow-up. It is shown that the currently used available diagnostic techniques for deep vein thrombosis are all able to identify the majority of patients who indeed have venous thrombosis. However, as result of its accuracy and practical advantages, compression ultrasound is the test of choice in the evaluation of symptomatic patients. Patients with a normal test outcome should be re-tested to detect the small proportion of patients with proximally extending calf vein thrombosis. In the strategy of repeated diagnostic testing, impedance plethysmography could be used as an alternative to ultrasonography. To obtain a reduction in repeat tests various diagnostic strategies have been evaluated and it was shown that these strategies, using non-invasive tests, can be as accurate and safe as the invasive reference strategy. The safeties of the various strategies were very similar; however, important differences were observed with respect to the practical implementation of the various diagnostic strategies. Simplification of the repeated testing strategy by using a D-dimer assay and/or a clinical decision rule seems to be promising. The reference standard for the diagnosis of pulmonary embolism remains pulmonary angiography. Several strategies based on non-invasive diagnostic methods have been evaluated for their safety and complexability. Perfusion-ventilation lung scanning is the most thoroughly evaluated non-invasive technique so far. It seems safe to withhold anticoagulant therapy in patients suspected of pulmonary embolism with a normal perfusion lung scan result; however, further testing is needed in the case of a non-diagnostic perfusion-ventilation lung scan result. At this moment angiography is the method of choice in this category of patients. D-dimer assays, clinical decision rules and ultrasound examinations of the legs seem to have a high potential to limit the need for angiography. Also, spiral computerized tomography and magnetic resonance imaging are promising techniques, but their role in the diagnostic management of pulmonary embolism is still uncertain.