Clinical Investigation
Right Ventricular Overload and RV Function
Right Ventricular Echocardiographic Parameters Are Associated with Mortality after Acute Pulmonary Embolism

https://doi.org/10.1016/j.echo.2014.11.012Get rights and content

Background

There is limited information on the utility of certain echocardiographic measurements, such as right ventricular (RV) strain analysis, in predicting mortality in patients with acute pulmonary embolism (PE).

Methods

A total of 211 patients with acute PE admitted to a medical intensive care unit (ICU) were retrospectively identified. Echocardiographic variables were prospectively measured in this cohort. The focus was on ICU, hospital, and long-term mortality.

Results

The mean age was 61 ± 15 years. Median Acute Physiology and Chronic Health Evaluation IV and simplified Pulmonary Embolism Severity Index scores were 60 (interquartile range, 40–71) and 2 (interquartile range, 1–2), respectively. Thirty-eight patients (18%) died during the sentinel hospitalization (13% died in the ICU). A total of 61 patients (28.9%) died during a median follow-up period of 15 months (interquartile range, 5–26 months). The echocardiographic variables associated with long-term mortality (from PE diagnosis) were ratio of RV to left ventricular end-diastolic diameter (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.2–4.8), tricuspid annular plane systolic excursion (HR, 0.53; 95% CI, 0.31–0.92), and RV–right atrial gradient (HR, 1.02; 95% CI, 1.01–1.4). ICU mortality was associated with ratio of RV to LV end-diastolic diameter (HR, 4.4; 95% CI, 1.3–15), RV systolic pressure (HR, 1.03; 95% CI, 1.01–1.05), tricuspid annular plane systolic excursion (HR, 0.4; 95% CI, 0.18–0.9), and inferior vena cava collapsibility < 50% (HR, 4.3; 95% CI, 1.7–11). These variables remain significantly associated with mortality after adjusting by Acute Physiology and Chronic Health Evaluation IV score, Pulmonary Embolism Severity Index score, or the use of thrombolytic agents. RV strain parameters were not correlated with hospital or long-term mortality.

Conclusions

Four simple parameters that measure different aspects of the right ventricle (ratio of RV to left ventricular end-diastolic diameter, RV systolic pressure, tricuspid annular plane systolic excursion, and inferior vena cava collapsibility) were independently associated with mortality in patients presenting with acute PE who were admitted to the ICU.

Section snippets

Subjects and Study Protocol

This was a single-center, retrospective cohort study that was approved by the Cleveland Clinic Institutional Review Board. We identified patients with acute PE admitted to Cleveland Clinic between February 2009 and January 2013 using the International Classification of Diseases, Ninth Revision, codes for PE and pulmonary infarction (415.1 and V12.51). For this analysis, we identified 235 patients who (1) had confirmed diagnoses of PE by computed tomographic angiography of the chest and/or a

Overall Patient Characteristics

We included a total of 211 patients in the final analysis. Patients had a mean age of 61 ± 15 years, and 107 (51%) were women. The majority were Caucasian (77%) or African American (22%). Three-quarters of the patients (n = 160 [76%]) were initially admitted to the ICU. Risk factors for the development of PE are shown in Table 1. Interestingly, 32 patients (15%) had at least two risk factors for PE. Among patients with histories of malignancy (n = 70), 34 were receiving chemotherapy at the

Discussion

In this single-center cohort of patients with acute PE admitted to a medical ICU, we examined whether certain echocardiographic parameters of interest relate to clinical outcomes. LV EDD, LVEF, estimated RVSP, and IVC collapsibility were associated with ICU mortality. Meanwhile, RV/LV EDD ratio, LV EDD, estimated RVSP, maximum TR jet velocity, leftward shifting of the IVS, and IVC collapsibility were associated with hospital mortality. An increase in the RV/LV EDD ratio or decreases in LV EDD,

Conclusions

Our study demonstrates that simple echocardiographic parameters are associated with ICU, hospital, and long-term mortality in patients presenting with acute PE. RV strain analysis by speckle-tracking imaging was not correlated with hospital or long-term mortality.

Acknowledgments

The authors thank Dr. Jorge Guzman for contributing the data on APACHE IV scores of ICU patients.

References (45)

  • A. Ribeiro et al.

    Pulmonary embolism: relation between the degree of right ventricle overload and the extent of perfusion defects

    Am Heart J

    (1998)
  • D. Jiménez

    Point: should systemic lytic therapy be used for submassive pulmonary embolism? Yes

    Chest

    (2013)
  • D. Miller et al.

    The relation between quantitative right ventricular ejection fraction and indices of tricuspid annular motion and myocardial performance

    J Am Soc Echocardiogr

    (2004)
  • J.A. Kline et al.

    Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure

    Chest

    (2009)
  • A. Vitarelli et al.

    Right ventricular function in acute pulmonary embolism: a combined assessment by three-dimensional and speckle-tracking echocardiography

    J Am Soc Echocardiogr

    (2014)
  • J.M. Brennan et al.

    Reappraisal of the use of inferior vena cava for estimating right atrial pressure

    J Am Soc Echocardiogr

    (2007)
  • A. Kent et al.

    Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index

    J Surg Res

    (2013)
  • E. Sugiura et al.

    Reversible right ventricular regional non-uniformity quantified by speckle-tracking strain imaging in patients with acute pulmonary thromboembolism

    J Am Soc Echocardiogr

    (2009)
  • M.D. Silverstein et al.

    Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study

    Arch Intern Med

    (1998)
  • A.T. Cohen et al.

    Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality

    Thromb Haemost

    (2007)
  • A. Torbicki et 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 Cardiology (ESC)

    Eur Heart J

    (2008)
  • M. ten Wolde et al.

    Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism

    Arch Intern Med

    (2004)
  • Cited by (65)

    • Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

      2022, Journal of Cardiothoracic and Vascular Anesthesia
      Citation Excerpt :

      A systematic review assessing the accuracy of emergency physician-performed ultrasound found a sensitivity of 96.1% and specificity of 96.8% for the diagnosis of DVT.79 Also, positive findings from the VUS DVT scan, when accompanied with FOCUS assessment of RV function (along with focused LUS), can be helpful in ruling out pulmonary embolism.80-82 Interfascial plane blocks play an emerging role in perioperative pain management.83

    • Prognostic Value of Computed Tomography Versus Echocardiography Derived Right to Left Ventricular Diameter Ratio in Acute Pulmonary Embolism

      2021, American Journal of the Medical Sciences
      Citation Excerpt :

      A number of studies have evaluated the role of various echocardiographic parameters as a method of classifying the severity of pulmonary embolism.4,12,13 Multiple ECHO derived parameters are predictive of adverse events after acute PE.12 Our study found a significant correlation between the CT derived RV:LV diameter ratio and ECHO derived RV:LV diameter ratio, suggesting that CT can indeed be used interchangeably or in place of ECHO for the acute evaluation of RV dilation and dysfunction.

    View all citing articles on Scopus
    View full text