Marcin Koć

Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry.

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors. 138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure <90 mmHg than in 107 normotensives (42% versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58–3.73; p<0.0001), while RiHT characteristics did not. Patients with RiHT had higher pulmonary embolism mortality than controls (19% versus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02). 30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls. Prognosis in patients with PE and RiHT is related to haemodynamic effects of PE, not RiHT morphology http://ow.ly/UCpja

Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction

BACKGROUND Patent foramen ovale (PFO) is an established risk factor for ischemic stroke. Since acute right ventricular dysfunction (RVD) observed in patients with PE can lead to right-to-left inter-atrial shunt via PFO, we hypothesized that PFO is a risk factor for ischemic stroke in PE with significant right ventricular dysfunction. METHODS 55 patients (31 F, 24M), median age 49 years (range 19-83 years) with confirmed PE underwent echocardiography for RVD and PFO assessment. High risk acute PE was diagnosed in 3 (5.5%) patients, while 16 (29%) hemodynamically stable with RVD patients formed a group with intermediate-risk PE. PFO was diagnosed in 19 patients (34.5%). Diffusion-weighted MRI of the brain for acute ischemic stroke (AIS) was performed in all patients 4.91 ± 4.1 days after admission. RESULTS AIS was detected by MRI in 4 patients (7.3%). Only one stroke was clinically overt and resulted in hemiplegia. All 4 AIS occurred in the PFO positive group (4 of 19 patients), and none in subjects without PFO (21.0% vs 0%, p=0.02). Moreover, all AIS occurred in patients with RVD and PFO, and none in patients with PFO without RVD (50% vs 0%, p=0.038). CONCLUSION Our data suggest that acute pulmonary embolism resulting in right ventricular dysfunction may lead to acute ischemic stroke in patients with patent foramen ovale. However, the clinical significance of such lesions remains to be determined.

d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism:

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

Age-adjusted plasma D-Dimer levels in suspected acute pulmonary embolism - a retrospective, single center study.

INTRODUCTION The conventional D‑dimer threshold (CDD) is characterized by high sensitivity and low specificity in diagnosing acute pulmonary embolism (PE) in older patients. A higher cut‑off level for D‑dimer has been proposed, aiming at increasing the specificity while maintaining high sensitivity. It is calculated by multiplying the patients age in years by a coefficient of 10 (YADD10). OBJECTIVES The aim of this study was to validate the clinical value of YADD10 in patients with suspected acute PE and to optimize this threshold to achieve increased specificity paired with high sensitivity. PATIENTS AND METHODS The medical records of 1022 patients with suspected acute PE, hospitalized between the years 2014 and 2016, were retrospectively analyzed. Patients older than 50 years, with complete medical records and good quality of multislice computed tomography (CT) scans were enrolled. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of the proposed thresholds were calculated and compared with those of the CCD. The number of computed tomography scans that could have been avoided with higher thresholds was determined. RESULTS The final analysis included 321 patients (176 women; mean age, 74.2 years; range, 51-101 years). Acute PE was confirmed in 135 patients. The sensitivity of CDD was 100%, and specificity-5.4%. The use of the YADD10 and YADD11 thresholds (obtained by multiplying by the coefficients of 10 and 11, respectively) resulted in maintaining high sensitivity, with increased specificity of 8.6% (YADD10) and 12.4% (YADD11). The number of unnecessary CT scans was reduced by 7%. CONCLUSIONS The YADD thresholds are characterized by high sensitivity and increased specificity when compared with CDD, thus allowing for a safe reduction of the number of CT scans. A prospective study should be conducted to validate these results.

Ocena przebiegu klinicznego u chorych z ostrą zatorowością płucną i skrzeplinami w jamach prawego serca. Doświadczenia jednego ośrodka

Introduction. Assessment of the clinical course of patients with acute pulmonary embolism (PE) and a right heart thrombus (RiHT). Material and methods . The analysis included 13 consecutive patients with echocardiographically detected RiHT and acute PE who were treated in our department. The endpoints were 30-day all-cause mortality and 30-day acute PE-related mortality. When a clear alternative cause of death was reported, a non-acute PE-related death was diagnosed and this contributed to 30-day all-cause mortality. All other fatalities were classified as related to acute PE. Results. High risk acute PE was diagnosed in 4 of 13 patients, and intermediate risk acute PE was diagnosed in the remaining 9 patients. Thrombolysis was the first-choice treatment in 4 (31%) patients, 6 (46%) patients were only anticoagulated, and the remaining 3 (23%) patients underwent surgical treatment. The main indication for embolectomy was RiHT entrapped in a patent foramen ovale (PFO). Two patients died during the first 30 days; they were hemodynamically unstable and deaths occurred within 48 hours since the diagnosis. No hemodynamically stable patients died within 30 days since the diagnosis. Conclusions . Thirty-day mortality in patients with RiHT depended mostly on the patient’s clinical condition and was not related to the presence or morphology of the thrombus. Patients with shock or hypotension may possibly benefit more from primary invasive treatment compared to drug therapy.

Tromboliza w ostrej zatorowości płucnej bez hipotensji — sukces kliniczny i elektrokardiograficzny

Despite better diagnostic and therapeutic possibilities, acute pulmonary embolism (APE) remains significant clinical problem. Many tests, including laboratory and visualizing are used to assess the prognosis. One of the most accessible and cheapest is unfortunately often omitted. This is the electrocardiogram (ECG). In the presented case we remind electrocardiographic signs of APE, we show possibility of indirect risk stratification based on ECG in patients with APE and, we would like to put the attention on changes in APE treatment guidelines.

Izolowany zawał prawej komory serca jako wynik ostrej zatorowości płucnej

Acute pulmonary embolism (APE) often leads to acute right ventricular overload, which is associated with patient’s condition deterioration. Dilation of the right chambers of the heart results in worsening in haemodynamic function. Severe overload of the right ventricle in the course of APE may also cause myocardial ischaemia. We present a case of young women who did not receive chronic treatment, in whom right ventricular myocardial infarction (RVMI) in the course of APE was diagnosed, and the diagnosis was confirmed with cardiac magnetic resonance (CMR) imaging.

RIGHT HEART THROMBI EUROPEAN REGISTRY

Assessment the prognostic significance of right heart thrombi (RiHT) in patients with pulmonary embolism (PE) according to RiHT size, shape, mobility in relation to established prognostic factors for 30 days mortality: hemodynamic instability, right ventricular dysfunction (RVD), Shock Index (SI)