Skip main navigation
Close Drawer MenuOpen Drawer Menu
Search
Quick Search in Journals
Quick Search anywhere
Advanced Search
Menu
  • Information
    • Previous
    Next
    Original Research

    Short-term Mortality in Acute Pulmonary Embolism: Clot Burden and Signs of Right Heart Dysfunction at CT Pulmonary Angiography

    Published Online:Oct 1 2012https://doi.org/10.1148/radiol.12110802

    Abstract

    In patients with acute pulmonary embolism, right heart dilatation was associated with higher risk of short-term mortality along with history of congestive heart failure and cancer.

    Purpose

    To assess the correlation between volumetric measurements of clot, semiquantitative clot burden indexes, and signs of right heart dysfunction at computed tomographic (CT) pulmonary angiography in patients with acute pulmonary embolism (PE) and to determine whether clot burden and signs of right heart dysfunction are associated with short-term mortality.

    Materials and Methods

    This retrospective study was institutional review board approved and HIPAA compliant. CT pulmonary angiographic studies (January 2007 through December 2007) with findings positive for PE were retrieved. Two readers evaluated signs of right heart dysfunction at CT pulmonary angiography, measured clot volume using a dedicated software program, and assessed clot burden using semiquantitative scores (Qanadli and Mastora). Spearman rank coefficient was used to investigate correlation between clot burden measures and signs of right heart dysfunction. Uni- and multivariate analyses were used to test association between CT pulmonary angiographic findings and short-term mortality.

    Results

    A total of 635 CT pulmonary angiographic studies from 635 patients (304 men, 331 women; mean age, 59 years) were included; 39 (6%) patients died within 30 days. Clot volume was strongly correlated with Qanadli score (ρ = 0.841, P < .01) and Mastora score (ρ = 0.863, P < .01) and moderately correlated (ρ = 0.378, P < .01) with the ratio of right ventricle diameter to left ventricle diameter (RV/LV ratio). Among the pulmonary angiographic signs, only increase in RV/LV ratio (cut-off value, 1.0) was independently associated with short-term mortality in multivariate analysis.

    Conclusion

    Clot volume strongly correlated with semiquantitative CT scores of clot burden, and greater clot volume was associated with higher incidence of right heart dilatation. Increase in RV/LV ratio was associated with short-term mortality; however, measures of clot burden were not.

    © RSNA, 2012

    Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12110802/-/DC1

    References

    • 1 Torbicki A, Perrier A, Konstantinides Set al.. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29(18):2276–2315. Crossref, Medline, Google Scholar
    • 2 Jaff MR, McMurtry MS, Archer SLet al.. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011;123(16):1788–1830. Crossref, Medline, Google Scholar
    • 3 Masotti L, Righini M, Vuilleumier Net al.. Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers. Vasc Health Risk Manag 2009;5(4):567–575. Crossref, Medline, Google Scholar
    • 4 Aujesky D, Obrosky DS, Stone RAet al.. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172(8):1041–1046. Crossref, Medline, Google Scholar
    • 5 Remy-Jardin M, Pistolesi M, Goodman LRet al.. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007;245(2):315–329. Link, Google Scholar
    • 6 Qanadli SD, El Hajjam M, Vieillard-Baron Aet al.. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001;176(6):1415–1420. Crossref, Medline, Google Scholar
    • 7 Mastora I, Remy-Jardin M, Masson Pet al.. Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data. Eur Radiol 2003;13(1):29–35. Crossref, Medline, Google Scholar
    • 8 Bankier AA, Janata K, Fleischmann Det al.. Severity assessment of acute pulmonary embolism with spiral CT: evaluation of two modified angiographic scores and comparison with clinical data. J Thorac Imaging 1997;12(2):150–158. Crossref, Medline, Google Scholar
    • 9 Collomb D, Paramelle PJ, Calaque Oet al.. Severity assessment of acute pulmonary embolism: evaluation using helical CT. Eur Radiol 2003;13(7):1508–1514. Crossref, Medline, Google Scholar
    • 10 Ghaye B, Ghuysen A, Willems Vet al.. Severe pulmonary embolism:pulmonary artery clot load scores and cardiovascular parameters as predictors of mortality. Radiology 2006;239(3):884–891. Link, Google Scholar
    • 11 Ghuysen A, Ghaye B, Willems Vet al.. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax 2005;60(11):956–961. Crossref, Medline, Google Scholar
    • 12 Araoz PA, Gotway MB, Harrington JR, Harmsen WS, Mandrekar JN. Pulmonary embolism: prognostic CT findings. Radiology 2007;242(3):889–897. Link, Google Scholar
    • 13 Wu AS, Pezzullo JA, Cronan JJ, Hou DD, Mayo-Smith WW. CT pulmonary angiography: quantification of pulmonary embolus as a predictor of patient outcome—initial experience. Radiology 2004;230(3):831–835. Link, Google Scholar
    • 14 Engelke C, Rummeny EJ, Marten K. Acute pulmonary embolism on MDCT of the chest: prediction of cor pulmonale and short-term patient survival from morphologic embolus burden. AJR Am J Roentgenol 2006;186(5):1265–1271. Crossref, Medline, Google Scholar
    • 15 Araoz PA, Gotway MB, Trowbridge RLet al.. Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism. J Thorac Imaging 2003;18(4):207–216. Crossref, Medline, Google Scholar
    • 16 Stein PD, Beemath A, Matta Fet al.. Enlarged right ventricle without shock in acute pulmonary embolism: prognosis. Am J Med 2008;121(1):34–42. Crossref, Medline, Google Scholar
    • 17 Moroni AL, Bosson JL, Hohn N, Carpentier F, Pernod G, Ferretti GR. Non-severe pulmonary embolism: prognostic CT findings. Eur J Radiol 2011;79(3):452–458. Crossref, Medline, Google Scholar
    • 18 Pech M, Wieners G, Dul Pet al.. Computed tomography pulmonary embolism index for the assessment of survival in patients with pulmonary embolism. Eur Radiol 2007;17(8):1954–1959. Crossref, Medline, Google Scholar
    • 19 Furlan A, Patil A, Park B, Chang CC, Roberts MS, Bae KT. Accuracy and reproducibility of blood clot burden quantification with pulmonary CT angiography. AJR Am J Roentgenol 2011;196(3):516–523. Crossref, Medline, Google Scholar
    • 20 Nakada K, Okada T, Osada H, Honda N. Relation between pulmonary embolus volume quantified by multidetector computed tomography and clinical status and outcome for patients with acute pulmonary embolism. Jpn J Radiol 2010;28(1):34–42. Crossref, Medline, Google Scholar
    • 21 Yount RV, Vries JK, Councill CD. The medical archival system: an information retrieval system based on distributed parallel processing. Inf Process Manag 1991;27(4):379–389. Crossref, Google Scholar
    • 22 Jones SE, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Radiology 2005;237(1):329–337. Link, Google Scholar
    • 23 Bae KT, Mody GN, Balfe DMet al.. CT depiction of pulmonary emboli: display window settings. Radiology 2005;236(2):677–684. Link, Google Scholar
    • 24 Reid JH, Murchison JT. Acute right ventricular dilatation: a new helical CT sign of massive pulmonary embolism. Clin Radiol 1998;53(9):694–698. Crossref, Medline, Google Scholar
    • 25 van der Meer RW, Pattynama PM, van Strijen MJet al.. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005;235(3):798–803. Link, Google Scholar
    • 26 Revel MP, Triki R, Chatellier Get al.. Is It possible to recognize pulmonary infarction on multisection CT images? Radiology 2007;244(3):875–882. Link, Google Scholar
    • 27 Ghanima W, Abdelnoor M, Holmen LO, Nielssen BE, Sandset PM. The association between the proximal extension of the clot and the severity of pulmonary embolism (PE): a proposal for a new radiological score for PE. J Intern Med 2007;261(1):74–81. Crossref, Medline, Google Scholar
    • 28 Breiman L, Friedman JH, Olshen RA, Stone CJ. Classification and regression trees. Boca Raton, Fla: Chapman & Hall/CRC, 1984. Google Scholar
    • 29 McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol 1971;28(3):288–294. Crossref, Medline, Google Scholar
    • 30 McIntyre KM, Sasahara AA. Determinants of right ventricular function and hemodynamics after pulmonary embolism. Chest 1974;65(5):534–543. Crossref, Medline, Google Scholar
    • 31 Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004;110(20):3276–3280. Crossref, Medline, Google Scholar
    • 32 Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121(3):877–905. Crossref, Medline, Google Scholar
    • 33 Quiroz R, Kucher N, Schoepf UJet al.. Right ventricular enlargement on chest computed tomography: prognostic role in acute pulmonary embolism. Circulation 2004;109(20):2401–2404. Crossref, Medline, Google Scholar
    • 34 Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997;134(3):479–487. Crossref, Medline, Google Scholar
    • 35 Smulders YM. Pathophysiology and treatment of haemodynamic instability in acute pulmonary embolism: the pivotal role of pulmonary vasoconstriction. Cardiovasc Res 2000;48(1):23–33. Crossref, Medline, Google Scholar
    • 36 Engelke C, Rummeny EJ, Marten K. Pulmonary embolism at multi-detector row CT of chest: one-year survival of treated and untreated patients. Radiology 2006;239(2):563–575. Link, Google Scholar
    • 37 Lu MT, Cai T, Ersoy Het al.. Comparison of ECG-gated versus non-gated CT ventricular measurements in thirty patients with acute pulmonary embolism. Int J Cardiovasc Imaging 2009;25(1):101–107. Crossref, Medline, Google Scholar
    • 38 Stein PD, Matta F, Yaekoub AYet al.. Reconstructed 4-chamber views compared with axial imaging for assessment of right ventricular enlargement on CT pulmonary angiograms. J Thromb Thrombolysis 2009;28(3):342–347. Crossref, Medline, Google Scholar

    Article History

    Received April 19, 2011; revision requested June 9; revision received January 31, 2012; accepted March 19; final version accepted May 18.
    Published online: Oct 2012
    Published in print: Oct 2012