Akut pulmoner embolide senkopun klinik, görüntüleme ve hemodinamik korelasyonları ve prognostik etkisi: Tek merkezli bir çalışma

Background: We aimed to determine the clinical, echocardiographic and hemodynamic correlates of syncope as a presenting symptom in pulmonary embolism and its impact on in-hospital and long-term outcomes. Methods: Between July 2012 and October 2019, a total of 641 patients with PE (277 males, 364 females; median age: 65 years; range, 51 to 74 years) in whom the diagnostic work-up and risk-based management were performed according to the current pulmonary embolism guidelines were retrospectively analyzed. Clinical, laboratory and imaging data of the patients were obtained from hospital database system. Results: Syncope was noted in 193 (30.2%) of patients on admission, and was associated with a significantly higher-risk status manifested by elevated troponin and D-dimer levels, a higher Pulmonary Embolism Severity Index scores, deterioration of right-to-left ventricular diameter ratio, right ventricular longitudinal contraction measures, the higher Qanadli score, and higher rates of thrombolytic therapies (p<0.001) and rheolytic– thrombectomy (p=0.037) therapies. In-hospital mortality (p=0.007) and minor bleeding (p<0.001) were significantly higher in syncope subgroup. Multivariate logistic regression analysis showed that higher Pulmonary Embolism Severity Index scores and right-to-left ventricular diameter ratio were independently associated with syncope, while aging and increased heart rate predicted in-hospital mortality. Malignancy and right-to-left ventricular diameter ratio at discharge, but not syncope, were independent predictors of cumulative mortality during follow-up. Conclusion: Syncope as the presenting symptom is associated with a higher risk due to more severe obstructive pressure load and right ventricular dysfunction requiring more proactive strategies in patients with pulmonary embolism. However, with appropriate risk-based therapies, neither in-hospital mortality nor long-term mortality can be predicted by syncope.Amaç: Bu çalışmada pulmoner embolide başvuru anında senkopun klinik, ekokardiyografik ve hemodinamik korelasyonları ve hastane içi ve uzun dönem sonuçlar üzerindeki etkisi incelendi. Ça­lış­ma pla­nı: Temmuz 2012-Ekim 2019 tarihleri arasında tanı testleri ve risk esaslı tedavisi mevcut pulmoner emboli kılavuzlarına göre yapılan toplam 641 pulmoner emboli hastası (277 erkek, 364 kadın; ort. yaş: 65 yıl; dağılım, 51-74 yıl) retrospektif olarak incelendi. Hastaların klinik, laboratuvar ve görüntüleme verileri hastane veri tabanı sisteminden elde edildi. Bulgular: Başvuru anında hastaların 193’ünde (%30.2) senkop belirlendi ve artmış troponin ve D-dimer düzeyleri, yüksek Pulmoner Emboli Şiddet İndeks skorları, sağ-sol ventrikül çapı oranında ve sağ ventrikülün uzunlamasına kontraksiyon ölçümlerinde kötüleşme, yüksek Qanadli skoru ve yüksek trombolitik tedavi (p<0.001) ve reolitik-trombektomi tedavi (p=0.037) oranları ile belirlendiği üzere anlamlı düzeyde daha yüksek risk durumu ile ilişkili bulundu. Hastane içi mortalitesi (p=0.007) ve minör kanama (p<0.001) senkop alt grubunda anlamlı düzeyde daha yüksek idi. Çok değişkenli lojistik regresyon analizinde, yüksek Pulmoner Emboli Şiddet İndeks skorları ve sağ-sol ventrikül çapı oranı senkop ile bağımsız düzeyde ilişkili bulunurken, yaşlanma ve artmış kalp hızı hastane içi mortalitesinin öngördürücüsüydü. Senkop değil fakat malignite ve taburculuk anında sağ-sol ventrikül çapı oranı, takip süresince toplam mortalitenin bağımsız öngördürücüleri idi. So­nuç: Başvuru semptomu olarak senkop, pulmoner embolide daha proaktif stratejiler gerektiren daha şiddetli tıkayıcı basınç yüküne ve sağ ventrikül disfonksiyonuna bağlı daha yüksek risk ile ilişkilidir. Ancak, riske göre uygun tedaviler uygulandığında ne hastane-içi mortalite ne de uzun dönem mortalite senkop tarafından öngörülebilmektedir

Reappraisal of the transthoracic echocardiographic algorithm in predicting pulmonary hypertension redefined by updated pulmonary artery mean pressure threshold

BACKGROUND: Although an adopted echocardiography algorithm based on tricuspid regurgitation jet peak velocity and suggestive findings for pulmonary hypertension has been utilized in the non-invasive prediction of pulmonary hypertension probability, the reliability of this approach for the updated hemodynamic definition of pulmonary hypertension remains to be determined. In this study, for the first time, we aimed to evaluate the tricuspid regurgitation jet peak velocity and suggestive findings in predicting the probability of pulmonary hypertension as defined by mean pulmonary arterial pressure > 20 mm Hg and > 25 mm Hg, respectively. METHODS: Our study group was comprised of the retrospectively evaluated 1300 patients (age 53.1 ± 18.8 years, female 62.1%) who underwent right heart catheterization with different indications between 2006 and 2018. All echocardiographic and right heart catheterization assessments were performed in accordance with the European Society of Cardiology/European Respiratory Society 2015 Pulmonary Hypertension Guidelines. RESULTS: Although tricuspid regurgitation jet peak velocity showed a significant relation with mean pulmonary arterial pressure in both definitions, suggestive findings offered a significant contribution only in predicting mean pulmonary arterial pressure ≥ 25 mm Hg but not for mean pulmonary arterial pressure > 20 mm Hg. In predicting the mean pulmonary arterial pressure > 20 mm Hg, tricuspid regurgitation jet peak velocity and suggestive findings showed an odds ratio of 2.57 (1.59-4.14, P 3.4 m/s were associated with 70% and 84% probability of mean pulmonary arterial pressure > 20 mm Hg and 60% and 76% probability of mean pulmonary arterial pressure ≥ 25 mm Hg, respectively. CONCLUSIONS: In contrast to those in predicting the mean pulmonary arterial pressure ≥ 25 mm Hg, suggestive findings did not provide a significant contribution to the probability of mean pulmonary arterial pressure > 20 mm Hg predicted by tricuspid regurgitation jet peak velocity solely. The impact of the novel mean pulmonary arterial pressure threshold on the echocardiographic prediction of pulmonary hypertension remains to be clarified by future studies

Maternal and fetal outcomes in pregnant women with pulmonary arterial hypertension: A single-center experience and review of current literature

BACKGROUND: Although pregnancy in women with pulmonary arterial hypertension has been considered a high-risk condition, current data regarding pregnancy with pulmonary arterial hypertension are scarce. In this study, we aimed to evaluate our single-center data on maternal and fetal outcomes in pregnant women with PAH and review currently available risk-based management strategies. METHODS: Our single-center study group comprised 35 women who became pregnant after the diagnosis of pulmonary arterial hypertension or in whom pulmonary arterial hypertension was diagnosed within early post-partum period. Clinical, laboratory, echocardiographic, and hemodynamic characteristics of pregnant and non-pregnant productive women with pulmonary arterial hypertension were compared, and similar comparison was also repeated for survivors and non-survivors in pregnant patient group. RESULTS: Pregnancy was noted in 15% of the 228 females with pulmonary arterial hypertension who were of hormonally productive ages, generally well-tolerated until delivery. Elective abortion and pre-term delivery were documented in 1 (2.8%) and 12 (35.3%) pregnant women, respectively. Switching to sildenafil was the standard medication during pregnancy. Cesarian section was the preferred method of delivery in all pregnant women with pulmonary arterial hypertension and was performed without any complication. Clinic deteoriation within the first week of delivery was observed in 5 (41.6%) patients. Maternal mortality was noted in 13 (37.1%) patients and was documented to cumulate within the first month of delivery. However, any sign predicting post-partum clinical deterioration was not found. No fetal mortality was observed. CONCLUSION: Despite the development of advanced therapies, pregnancy in pulmonary arterial hypertension still carries a high mortality risk and requires multi-disciplinary expert center care with more proactive management strategies

A new index for the prediction of in-hospital mortality in patients with acute pulmonary embolism: The modified shock index

BACKGROUND: Pulmonary embolism severity index, its simplified version, and shock index have been used for risk stratification in acute pulmonary embolism. In this study, we proposed a modification in severity index and evaluated the correlates and prognostic value of modification in severity index in this setting. METHODS: The study group comprised retrospectively evaluated 181 patients with acute pulmonary embolism. Systematic workup including pulmonary embolism severity index, its simplified version, shock index, biomarkers, and echocardiographic and multidetector computed tomography assessments was performed in all patients. Moreover, we calculated modification in severity index by multiplying original shock index (heart rate/systolic blood pressure ratio) and a third component, 1/pulse oxymetric saturation (pSat O2%) ratio. The primary endpoint was defined as all-cause mortality and hemodynamic collapse during the hospital stay. RESULTS: On the basis of initial risk stratification, ultrasound-assisted thrombolysis, systemic tissue-type plasminogen activator, and unfractionated heparin therapies were utilized in 83 (45.9%), 37 (20.4%), and 61 (33.7%) patients, respectively. The primary end-point occurred in 13 (7.2%) patients. Receiver-operating curve analysis revealed that modification in severity index had the highest area under the curve of 0.739 (0.588-0.890, P =.002) compared with shock index, pulmonary embolism severity index, or its simplified version. The modification in severity index > 0.989 predicted primary endpoint with 73% sensitivity and 54% specificity. CONCLUSIONS: The modification in severity index seems to be a simple, quick, and compre-hensive risk assessment tool for bedside evaluation at initial stratification, in monitoring the clinical benefit from therapies, and decision-making for escalation to other reperfusion strategies in patients with acute pulmonary embolism. However, the prognostic value of modification in severity index needs to be validated with further studies

A novel composed index to evaluate the right ventricle free-wall adaptation against ventricular wall stress in acute pulmonary embolism

Background: Pulmonary embolism severity index and simplified pulmonary embolism severity index have been utilized in initial risk evaluation in patients with acute pulmonary embolism. However, these models do not include any imaging measure of right ventricle function. In this study, we proposed a novel index and aimed to evaluate the clinical impact. Methods: Our study population comprised retrospectively evaluated 502 patients with acute pulmonary embolism managed with different treatment modalities. Echocardiographic and computed tomographic pulmonary angiography evaluations were performed at admission to the emergency room within maximally 30 minutes. The formula of our index was as follows: (right ventricle diameter × systolic pulmonary arterial pressure-echo)/(right ventricle free-wall diameter × tricuspid annular plane systolic excursion). Results: This index value showed significant correlations to clinical and hemodynamic severity measures. Only pulmonary embolism severity index, but not our index value, independently predicted in-hospital mortality. However, an index value higher than 17.8 predicted the long-term mortality with a sensitivity of 70% and specificity of 40% (areas under the curve = 0.652, 95% CI, 0.557-0.747, P = .001). According to the adjusted variable plot, the risk of long-term mortality increased until an index level of 30 but remained unchanged thereafter. The cumulative hazard curve also showed a higher mortality with high-index value versus low-index value. Conclusions: Our index composed from measures of computed tomographic pulmonary angiography and transthoracic echocardiography may provide important insights regarding the adaptation status of right ventricle against pressure/wall stress in acute pulmonary embolism, and a higher value seems to be associated with severity of the clinical and hemodynamic status and long-term mortality but not with in-hospital mortality. However, the pulmonary embolism severity index remained as the only independent predictor for in-hospital mortality

Reappraisal of echocardiographic algorithm in predicting the pulmonary hypertension redefined by updated pulmonary artery mean pressure treshold

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May High Serum Triglyceride Levels be a Predictor of New Silent Ischemic Lesions Detected with DW-MRI After Carotid Stenting?

INTRODUCTION: Silent ischemic lesions(CIL) frequently occur after carotid artery stenting(CAS) and are associated with poor long-term prognosis. The effect of blood triglyceride (TG) level on CIL after CAS is yet clear. We investigated the effect of serum TG level on post-procedure CIL in patients undergoing CAS. METHODS: 57 patients who underwent CAS were included in the study, and diffusion-weighted magnetic resonance imaging was conducted before and after CAS. The primary endpoint was new CILs after CAS. The effects of pre-procedural TG, total cholesterol, HDL, and LDL levels on the primary endpoint were investigated. RESULTS: Of the patients 46 (80.7%) were male, median age was 69(60-73) years, and 27 (47.3%) were symptomatic. After the procedure, ipsilateral new CILs were detected in 28 (49.1%) patients. NASCET stenosis %, being symptomatic and using aspirin before the procedure were associated with the presence of new ipsilateral CILs. In multivariate logistic regression analysis, pre-procedural TG level was the only independent predictor of ipsilateral new CILs after the procedure. DISCUSSION AND CONCLUSION: Our study reveals that high TG level is an independent risk factor for new CILs after CAS. Since CILs increase the risk for future ischemic events, TG as a simple, inexpensive, effective, and modifiable marker, can provide information for intense medical treatment, early intervention, and the prognosis