Current insights for catheter-directed therapies in acute pulmonary embolism: Systematic review and our single-center experience

In this review, the current status of the worldwide experience on different catheter-directed treatment systems utilized as alternative reperfusion methods in acute pulmonary-embolism was evaluated, and the risk stratification algorithms in which catheter-directed treatments may be implemented, source of evidence in this setting, adjudication of benefits and risks of available techniques, and innovative multidisciplinary frameworks for referral patterns and care delivery were discussed. Moreover, our perspectives on risk-based catheter-directed treatment utilization strategies in acute pulmonary embolism were summarized

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

Ses kısıklığının ciddi pulmoner hipertansiyonu olan hastalarda pulmoner arter anevrizması ve sol ana koroner artere dıştan basıyı göstermedeki rolü

OBJECTIVE: Pulmonary artery (PA) enlargement is a common finding in patients with severe pulmonary hypertension (PH) and may be associated with extrinsic compression of the left main coronary artery (LMCA-Co) and/or compression of the left recurrent laryngeal nerve resulting in hoarseness named as Ortner syndrome (OS). In this study, we evaluated the diagnostic impact of OS in predicting the PA aneurysm and significant LMCA-Co in patients with PH. METHODS: Our study population comprised retrospectively evaluated 865 with PH confirmed with the right heart catheterization between 2006 and 2022. Patients underwent coronary angiography due to several indications, including the presence of a PA aneurysm on echocardiography, angina symptoms, or the incidental discovery of LMCA-Co on multidetector computed tomography. The LMCA-Co is defined as diameter stenosis ³ 50% in reference distal LMCA segment on two consecutive angiographic planes. RESULTS: The LMCA-Co and hoarseness were documented in 3.8% and 4.3% of patients with PH, respectively. Increasing PA diameter was significantly associated with worse clinical, hemodynamic, laboratory, and echocardiographic parameters. The receiver operating curves revealed that the PA diameter >41 mm was cutoff for hoarseness (AUC: 0.834; sensitivity 69%, specificity 84%, and negative predictive value 98%), and PA diameter >35 mm was cutoff for LMCA-Co >50% (AUC: 0.794; sensitivity 89%, specificity 58 %, and negative predictive value 99%). An odds ratio of hoarseness for LMCA-Co was 83.3 (95% confidence interval; 36.5-190, P < 0.001) with 3.2% sensitivity, 98.7% specificity, and 59% positive and 98% negative predictive values. CONCLUSION: In this study, a close relationship was found between the presence of hoarseness and the probability of extrinsic LMCA-Co by enlarged PA in patients with severe PH. Therefore, the risk of LMCA-Co should be taken into account in patients with PH suffering from hoarseness.Amaç: Pulmoner arter (PA) genişlemesi, şiddetli pulmoner hipertansiyonu (PH) olan hastalarda sık görülen bir bulgu olup Ortner sendromu (OS) adını alarak sol ana koroner arterin (LMCA) dıştan basısı ve/veya sol rekürren laringeal sinirin basısı ile sonuçlanarak ses kısıklığına neden olabilir. Bu çalışmada OS’nin PH hastalarında PA anevrizmasını ve anlamlı LMCA basısını öngördürmede tanısal etkisini değerlendirmeyi amaçladık. Yöntem: Çalışma popülasyonu, 2006 ve 2022 yılları arasında sağ kalp kateterizasyonu ile doğrulanan PH ile retrospektif olarak değerlendirilen 865 hastayı içermektedir. Hastalara, ekokardiyografide PA anevrizmasının varlığı, anjina semptomları veya çok kesitli bilgisayarlı tomografide tesadüfen LMCA basısı saptanması gibi endikasyonlarla invaziv koroner anjiyografi yapılmıştır. LMCA basısı, ardışık iki anjiyografik düzlemde referans distal LMCA segmentinde %50’nin üzerinde çap darlığı olarak tanımlanmıştır. Bulgular: LMCA basısı ve ses kısıklığı PH hastalarının sırasıyla %3.8 ve %4.3’ünde gösterilmiştir. Artan PA çapı daha kötü klinik, hemodinamik, laboratuvar ve ekokardiyografik parametrelerle anlamlı şekilde ilişkili bulundu. ROC eğrileri, 41 mm ve üzerindeki PA çap artışının ses kısıklığı için sınır değer olduğunu ortaya çıkardı (EAA: 0,834; duyarlılık %69, özgüllük %84, negatif öngörü değeri %98) ve PA çapının 35 mm ve üzerinde olması ise LMCA basısı için sınır değer olarak bulundu (EAA: 0,794; duyarlılık %89, özgüllük %58, negatif öngörü değeri %99). LMCA basısı için ses kısıklığının Odds oranı, %53,2 duyarlılık, %98,7 özgüllük, %59 pozitif ve %98 negatif öngörü değerleri ile 83,3 (%95 Güven Aralığı; 36,5 -190, P < 0,001) bulundu. Sonuç: Bu çalışmada şiddetli PH’lı hastalarda ses kısıklığının varlığı ile genişlemiş PA ile dıştan LMCA basısı olasılığı arasında yakın bir ilişki bulundu. Bu nedenle, ses kısıklığı şikayeti olan PH hastalarında LMCA basısı riski dikkate alınmalıdır

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

Remembering the Occam’s Razor: Could simple electrocardiographic findings provide relevant predictions for current hemodynamic criteria of pulmonary hypertension?

Background: We evaluated the predictive value of electrocardiographic (ECG) findings for pulmonary hemodynamics assessed by right heart catheterization (RHC). Methods: Our study population comprised 562 retrospectively evaluated patients who underwent RHC between 2006 and 2022. Correlations between ECG measures and pulmonary arterial systolic and mean pressures (PASP and PAMP) and pulmonary vascular resistance (PVR) were investigated. Moreover, receiver operating characteristic (ROC) curve analysis assessed the predictive value of ECG for pulmonary hypertension (PH) and precapillary PH. Results: The P-wave amplitude (Pwa) and R/S ratio (r) in V1 and V2, Ra in augmented voltage right (aVR), right or indeterminate axis, but not P wave duration (Pwd) or right bundle branch block (RBBB) significantly correlated with PASP, PAMP, and PVR (P 0.16 mV, Ra in aVR > 0.05 mV, QRS axis > 100° and R/Sr in V1 > 0.9 showed the highest area under curve (AUC) values for PAMP > 20 mm Hg. Using the same cutoff value, Ra in aVR, Pwa, QRS axis, and R/Sr in V1 showed highest predictions for PVR > 2 Wood Units (WU). Conclusion: In this study, Pwa, Ra in aVR, right or indeterminate axis deviations, and R/Sr in V1 and V2 showed statistically significant correlations with pulmonary hemodynamics, and Ra in aVR, R/Sr in V2 and V1, QRS axis, and Pwa contributed to variance for PASP, PAMP, and PVR, respectively. Moreover, Pwa, Ra in aVR, QRS axis, and R/Sr in V1 seem to provide relevant predictions for PH and precapillary PH

Highlights From Acc 15 Scientific Sessions: Part 2

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