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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 238-242

Association of computed tomography pulmonary angiography findings with clinical outcome in patients with acute pulmonary embolism


1 Department of Radio Diagnosis, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission27-Nov-2020
Date of Acceptance08-May-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Pavan Kumar G. Kale
Department of Radiodiagnosis SVIMS, Alipiri Road, Tirupati - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_197_20

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  Abstract 


Context: Acute pulmonary embolism (PE) is one of the common and potentially fatal medical emergencies. The short-term mortality of PE ranges from less than 1% in hemodynamically stable patients to over 90% in patients presenting with cardiopulmonary arrest.[1] Patients presenting with PE have a high risk of mortality in the first 30 days.[2],[3],[4],[5] Echocardiography is routinely done in cases of PE for knowing cardiac status but echo being highly operator dependent, Computed Tomography (CT) pulmonary angiography (CTPA) can provide an alternative with lesser operator dependence. The main purpose of this study is to assess the prognostic value of different parameters measured by multi-detector CT pulmonary angiography (CTPA) in evaluating the clinical outcome of acute PE patients.
Aim and Objectives: To study association of left atrium (LA) volume, LA volume index, RVV/LVV ratio, IVC reflux, interventricular septal bowing with clinical outcome.
Methods and Materials: The prospective study was conducted in the Department of Radio-Diagnosis, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati in the time frame of March 2018 to June 2019. A total of 46 cases that were confirmed to have acute pulmonary thromboembolism on CTPA meeting the study criteria were studied for location of emboli, LA volume, LA volume index, RVV/LVV ratio, IVC reflux, interventricular septal bowing. The parameters were compared with adverse clinical outcomes which were defined as death within 30 days or escalation of therapy, according to the MAPPET-3 ( Management Strategies and Prognosis in Pulmonary Embolism Trial-3) study criteria.[7]
Statistical Analysis Used: Chi-square test was used for comparisons of categorical variables, and Student t-test was used for comparisons in the distributions of continuous variables by using IBM SPSS statistics 20. A P value <0.05 was considered significant.
Results: Our study included 46 patients belonging to age range of 18 to 83 years with evidence of pulmonary thromboembolism on CTPA study. Out of these, 18 (39%) patients had adverse events, where 17 (37%) patients died within 30 days, and 1 (2%) had a cardiac arrest where he was revived after cardiopulmonary resuscitation within 30 days from diagnosis of acute PE. There was no difference in the distribution of age, sex or other comorbidities between the patients who had adverse events and those who did not. In our study, patients with centrally lodged thrombi showed higher mortality and other adverse events than patients with more peripherally lodged PE (p value = 0.022). There was no evidence of any statistically significant association between the IVC reflux, septal bowing, cardiac volume parameters with adverse events within 30 days of diagnosis of acute PE.
Conclusion: In our study, we found the location of thrombus on CTPA to be a significant factor in predicting the adverse outcome. Other parameters like LA volume, LA volume index, RVV/LVV ratio, IVC reflux interventricular septal bowing did not demonstrate a significant relationship with 30-day adverse outcomes. The use of cardiac volumes in predicting the clinical outcome did not show any significant relationship, and this could be due to underlying conditions like hypertension, smoking, systemic diseases. The use of cardiac chamber volumes in predicting clinical outcome needs to be studied on a larger sample size to look for the role of other systemic factors affecting its volume.

Keywords: Interventricular septal bowing, IVC reflux, LA volume, LA volume index, pulmonary embolism, RVV/LVV ratio


How to cite this article:
Bimineni C, G. Kale PK, Lakshmi A Y, Rajasekhar D, Madhusudan M. Association of computed tomography pulmonary angiography findings with clinical outcome in patients with acute pulmonary embolism. J NTR Univ Health Sci 2021;10:238-42

How to cite this URL:
Bimineni C, G. Kale PK, Lakshmi A Y, Rajasekhar D, Madhusudan M. Association of computed tomography pulmonary angiography findings with clinical outcome in patients with acute pulmonary embolism. J NTR Univ Health Sci [serial online] 2021 [cited 2022 May 28];10:238-42. Available from: https://www.jdrntruhs.org/text.asp?2021/10/4/238/339816




  Introduction Top


Acute pulmonary embolism (PE) is one of the common and potentially fatal medical emergencies, with variable short-term mortality of less than 1% in hemodynamically stable patients to over 90% in those with cardiopulmonary arrest.[1] In patients presenting with PE, it is found that the risk of mortality is high in the first 30 days.[2] Echocardiography is routinely done in cases of PE for knowing cardiac status but echo being operator dependent, CT pulmonary angiography (CTPA) can provide an alternative with lesser operator dependence. In this study we wanted to assess the usefulness of parameters measured by multi-detector CT pulmonary angiography (CTPA) in predicting the clinical outcome of acute PE patients.


  Methods and materials Top


The prospective study was conducted in Department of Radio-Diagnosis, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati after obtaining clearance from the Institutional Protocol Approval Committee and the Institutional Ethics Committee AS/11/EC/SVIMS/2017. DATED, 02/APRIL/2018. All the patients undergoing CTPA in the Department of Radiology, SVIMS, Tirupati and who were confirmed to have pulmonary embolism were included. Where s patients with renal impairment, pre-existing left ventricular ejection fraction <50%, pregnancy, patients unwilling to participate, suboptimal CT angiography study, patients with allergic history to iodinated contrast medium were excluded from the study.

A total of 51 cases that were confirmed to have acute pulmonary thromboembolism on CTPA and were included in the study. 5 cases were excluded because, 2 of them had mitral stenosis with impaired left heart function, anomalous pulmonary venous connection was found in 1 patient, 2 cases were excluded due to suboptimal CTPA study. The final study cohort included 46 patients. All patients underwent Non–ECG-gated chest CT on a 128-slice multidetector-row CT system (Somatom definition 128, Siemens). Contrast medium enhancement was achieved with 100 ml of a non-ionic iodinated contrast medium injected at 4 ml/s using a power injector followed by a saline case of 50 ml at 3.5 ml/s. Automated bolus triggering (CARE BOLUS TRACKING) was used with a region of interest in the superior vena cava. Image review was done on Siemens workstation using SYNGO software. Images were reviewed by two radiologists. All the scans were studied for location of emboli, LA volume, LA volume index, RVV/LVV ratio, IVC reflux, interventricular septal bowing on. Emboli appear as a hypodense filling defect in pulmonary arterial system. The distribution of each patient's emboli was classified as central PE when main or lobar pulmonary arterial emboli were involved and peripheral PE when there are only segmental or sub-segmental emboli are seen.

Atrial and ventricular volume measurement was done on 1 mm thickness axial images. The 3D volumetric analysis of both atria was performed using the volume analysis application of the workstation (Volume Analysis, Siemens). The endocardial contours were segmented semi-automatically and measured on 4-chamber reconstruction and (RA) volume, left atrium (LA) volume, RA/LA volumes ratios, RVV/LVV were evaluated. LA volume index was calculated as a ratio of left atrial volume and body surface area. Body surface area was measured by using patient's height and weight. Septal bowing i.e., Deviation of the interventricular septum was evaluated as described in [Table 1].[6] Flattened septum and septal bowing were considered as abnormal positions of the septum indicating RV strain.
Table 1: Depicting septal deviation[6]

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The entry of contrast into IVC, before appearance in the systemic circulation, was considered as IVC reflux. The severity of reflux of contrast medium into the IVC or hepatic veins was graded according to a previously published scale [Table 2].[7] The degree of reflux was grouped into non-substantial (grades I to III) and substantial (grades IV to VI).
Table 2: Depicting grades of ivc reflux[7]

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The data from CTPA was compared with adverse clinical outcomes which were defined as death within 30 days or escalation of therapy, according to the MAPPET-3 study criteria. The data from CTPA was compared with adverse clinical outcomes. Adverse clinical outcomes are defined as death within 30 days or escalation of therapy, according to the MAPPET-3 study criteria, including cardiopulmonary resuscitation, endotracheal intubation, and vasopressors for systemic hypotension, thrombolysis, or surgical embolectomy.[8]

Demographic information such as age, sex and medical history of cancer, coronary artery disease, congestive heart failure, diabetes mellitus, chronic lung disease, and renal insufficiency were recorded. Data was statistically described in terms of range, mean and standard deviation (±SD), frequencies (number of cases) and relative frequencies (%). Chi-square test was used for comparisons of categorical variables, and Student t-test was used for comparisons in the distributions of continuous variables by using IBM SPSS statistics 20. A P value <0.05 was considered significant.


  Results Top


Of the 46 patients 21 were male, 25 were female with age range of 18 to 83 years. Out of these, 18 (39%) patients had adverse events, where 17 (37%) patients died within 30 days, and 1 (2%) had a cardiac arrest where he was revived after cardiopulmonary resuscitation within 30 days from diagnosis of acute PE. There is no significant difference in distribution of age, sex or other comorbidities mentioned in the below [Table 3] between the patients who had adverse events and those who did not.
Table 3: Represents the relation of demographic factors and comorbid conditions with adverse events within 30 days of diagnosis of acute pe

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  Discussion Top


In our study there was no evidence of any statistically significant relationship between the IVC reflux, septal bowing with adverse events within 30 days of diagnosis of acute PE. In our study, patients with centrally lodged thrombi showed higher 30 days mortality and other adverse events than patients with more peripherally lodged PE (p value = 0.022). There was no evidence of any association between cardiac volume parameters and clinical outcome of patients [Table 4].
Table 4: Represents the relation between cardiac volumes and adverse events within 30 days of diagnosis of acute pe

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There was no evidence of any statistically significant relationship between the IVC reflux and septal bowing with adverse events within 30 days of diagnosis of acute PE. In our study, patients with centrally lodged thrombi showed higher mortality and other adverse events than patients with more peripherally lodged PE (p value = 0.022) [Table 5].
Table 5: Represents the location of thrombus, ivc reflux, septal bowing in relation with adverse events within 30 days of diagnosis of acute pe

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The results of the current study show that the central location of pulmonary thrombus is associated with an increase in adverse effects within 30 days of diagnosis of acute PE in comparison with only peripheral location. The results are in accordance with findings of Alonso Martinez JL, et al.,[9] in which they studied a total of 530 patients diagnosed with PE. Similar to our study in a study by Vedovati, et al.,[10] comprising 549 cases of acute PE who underwent CTPA showed that the incidence of all-cause death or clinical deterioration was 11.2%, 11.1%, and 5.7% in patients with central, lobar, and distal emboli, respectively. In our study of 46 patients, interventricular septum position was abnormal in 28 patients, out of which only 10 (55.55%) had adverse outcomes, showing no significant association of interventricular septal bowing in predicting adverse outcome (p value = 0.554).

According to Kang DK et al.,[6] abnormal position of the interventricular septum is an independent predictive of adverse outcomes in patients with acute PE, which is contrary to finding in our study. Naim Ceylan et al.,[11] in a study comprising on patients with acute PE showed that there is no significant relationship in between abnormal interventricular septum and 30-day mortality (p = 0.55). These findings are similar to our study. In our study, substantial IVC reflux is seen in 21 patients, out of which 10 patients (55.55%) had adverse events 11 (39.28%) patients did not have any adverse events showing there is no statistically significant association between IVC reflux and clinical outcome (p value = 0.280).

Similar to our study in their study Naim Ceylan, et al.,[11] showed that there is no significant relationship in between (p = 0.55). In a study conducted by Kang DK et al.,[6] they concluded that IVC reflux helps in predicting 30-day mortality in patients with acute PE, (p value <0.001) these findings are in contradiction to our study. Aviram et al.,[12] in their study of observed that IVC reflux could significantly predict 30-day mortality. (p value 0.008). In our study, the mean LA volume in non-adverse outcome group of 28 patients was 45.76 (+/-18.68) ml and in adverse outcome group of 18 patients was 48.22 (+/- 15.23) ml (p value 0.643]. In a retrospective study conducted by Aviram et al.,[13] showed that mean LA volume in dead patients was 57.5 +/- 21.78 ml and in alive patients was 70.1 +/-24.07 ml (p value-0.002).

Dong Jia et al.,[14] through their study concluded that reduced LA volume serves as a prognostic factor in predicting short term adverse outcome in patients with acute PE. In our study RVV/LVV ratio was 1.955 (+/-1.478) in adverse outcome group and was 1.847 (+/-1.247) in non-adverse outcome group showing no significant association between RVV/LVV ratio and clinical outcome. (p value-0.792). In a study conducted by Kang DK, et al.,[6] found a significant association between RVV/LVV ratio and adverse clinical outcome (p value <0.001), these findings are in contradiction to our study. In a study conducted by Galit Aviram, et al.,[7] where they evaluated 155 consecutive patients with positive CTPAs and a control group of 52 consecutive patients with negative CTPAs found RVV/LVV ratios greater than 1.5 (15 patients) had an increased HR of 2.9 (1.2 – 6.9) compared to those with ratios below 1.0 (67 patients) (p value = 0.015), these findings are in contradiction to our study.


  Conclusions Top


In our study, we found the location of thrombus on CT to be a significant factor in predicting the adverse outcome. Other parameters like LA volume, LA volume index, RVV/LVV ratio, IVC reflux interventricular septal bowing did not demonstrate a significant relationship with 30-day adverse outcomes.

Limitations

We had a relatively smaller sample size, hence further validation is required with a larger sample. Our is a single centre study. The investigators were not blinded to clinical outcome. Inter observer variability was not assessed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Aviram G, Sirota-Cohen C, Steinvil A, Keren G, Banai S, Sosna J, et al. Automated volumetric analysis of four cardiac chambers in pulmonary embolism: A novel technology for fast risk stratification. Thromb Haemost 2012;108:384-93.  Back to cited text no. 7
    
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Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143-50.  Back to cited text no. 8
    
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Alonso Martinez JL, Anniccherico Sánchez FJ, Urbieta Echezarreta MA, García IV, Álvaro JR. Central versus peripheral pulmonary embolism: Analysis of the impact on the physiological parameters and long-term survival. N Am J Med Sci 2016;8:134-42.  Back to cited text no. 9
    
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Vedovati MC, Becattini C, Agnelli G, Kamphuisen PW, Masotti L, Pruszczyk P, et al. Multidetector CT scan for acute pulmonary embolism: Embolic burden and clinical outcome. Chest 2012;142:1407-24.  Back to cited text no. 10
    
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Ceylan N, Tasbakan S, Bayraktaroglu S, Cok G, Simsek T, Duman S, et al. Predictors of clinical outcome in acute pulmonary embolism: Correlation of CT pulmonary angiography with clinical, echocardiography and laboratory findings. Acad Radiol 2011;18:47-53.  Back to cited text no. 11
    
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Aviram G, Rogowski O, Gotler Y, Bendler A, Steinvil A, Goldin Y, et al. Real-time risk stratification of patients with acute pulmonary embolism by grading the reflux of contrast into the inferior vena cava on computerized tomographic pulmonary angiography. J Thromb Haemost 2008;6:1488-93.  Back to cited text no. 12
    
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Galit Aviram ES, Bendet A, Shmueli H, Ziv-Baran T, Amitai Y, Friedensohn L, et al. Prediction of mortality in pulmonary embolism based on left atrial volume measured on CT pulmonary angiography. Chest 2016;149:667-75.  Back to cited text no. 13
    
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Jia D, Li XL, Zhang Q, Hou G, Zhou XM, Kang J. A decision tree built with parameters obtained by computed tomographic pulmonary angiography is useful for predicting adverse outcomes in non-high-risk acute pulmonary embolism patients. Respir Res 2019;20:187.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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