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Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis

Graeme Prosperi-Porta, Paul Ronksley, Omid Kiamanesh, Kevin Solverson, Pouya Motazedian, Jason Weatherald
European Respiratory Review 2022 31: 220120; DOI: 10.1183/16000617.0120-2022
Graeme Prosperi-Porta
1University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
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Paul Ronksley
2O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
3Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Omid Kiamanesh
4Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
5Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Kevin Solverson
6Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
7Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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  • ORCID record for Kevin Solverson
Pouya Motazedian
1University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
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Jason Weatherald
5Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
7Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
8Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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  • For correspondence: jason.weatherald@albertahealthservices.ca
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  • FIGURE 1
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    FIGURE 1

    PRISMA diagram showing literature search and selection of right ventricular dysfunction (RVD) in pulmonary embolism (PE) articles [11]. A total of 6402 articles were identified (1757 duplicates removed). 4675 articles were screened by title and abstract with 251 articles determined for eligibility. 196 articles were excluded, leaving a total of 55 articles that were included in the systematic review. VQ: ventilation/perfusion; CT: computed tomography; RVD: right ventricular dysfunction; TTE: transthoracic echocardiography.

  • FIGURE 2
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    FIGURE 2

    Forest plots for studies assessing right ventricular dysfunction (RVD) in pulmonary embolism (PE) for a) combined adverse events, b) all-cause mortality outcome and c) PE-related mortality outcome. Dashes (–) represent missing data. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird. #: Yates correction.

  • FIGURE 3
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    FIGURE 3

    Meta-analysis of studies assessing right ventricular dysfunction (RVD) in pulmonary embolism (PE) for haemodynamically stable patients at intermediate risk of outcomes. a) Combined adverse events. b) All-cause mortality. c) PE-related mortality. Dashes (–) represent missing data. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird.

  • FIGURE 4
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    FIGURE 4

    Individual measures of right ventricular dysfunction (RVD) showing the pooled odds ratios of a) decreasing tricuspid annulus plane systolic excursion (TAPSE) per mm on combined adverse events, b) decreasing TAPSE per mm on all-cause mortality, c) increasing right ventricular to left ventricular diameter ratio (RV/LV) per 1 unit change on combined adverse events, d) increasing RV/LV per 1 unit change on all-cause mortality, e) increasing pulmonary artery systolic pressure (PASP) per 10 mmHg on combined adverse events and f) increasing PASP per 10 mmHg on all-cause mortality. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird.

Tables

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  • TABLE 1

    Summary characteristics of articles included in the systematic review

    Study characteristicsNumber (%)
     Cohort (n=55), n (%)54 (98.2)
     Case control (n=55), n (%)1 (1.8)
     Prospective (n=54), n (%)32 (58.2)
     Multicentre (n=55), n (%)19 (34.5)
     Aim of study to assess TTE (n=55)29 (52.7)
    Patient characteristics
     Number of haemodynamically stable patients with TTE (n=53), n17 090
     Number of haemodynamically stable patients with TTE per study (n=53), median (IQR)179 (96–462)
     Female study patients (n=52), n (%)8975 (52.8)
     Male study patients (n=52), n (%)8036 (47.2)
     Number of patients with RVD (n=44), n (%)5399 (37.8)
     Number of patients with no RVD (n=44), n (%)8889 (62.2)
    Geographic region (n=55)
     Asia/Oceania13 (23.6)
     Europe31 (56.4)
     Americas11 (20.0)
    PE risk group in study (n=55)
     Low and intermediate risk44 (80.0)
     Intermediate risk5 (9.1)
     All risk6 (10.9)
    RVD definition (n=55)
     Composite RVD definition37 (67.3)
     Individual variable RVD definition18 (32.7)
    Time to TTE (n=40)
     ≤24 h11 (27.5)
     ≤48–72 h29 (72.5)
    Primary outcome studied (n=55)
     Combined adverse events31 (56.4)
     All-cause mortality19 (34.5)
     PE-related mortality5 (9.9)
    Outcomes studied (n=55)
     Combined adverse events37 (45.7)
     All-cause mortality27 (33.3)
     PE-related mortality17 (21.0)
    Follow-up (n=55)
     In hospital or <14 days31 (56.3)
     14–30 days24 (43.7)

    High-risk patients are defined by the presence of haemodynamic instability, intermediate-risk patients are haemodynamically stable but have a simplified pulmonary embolism severity index of >0 and may have evidence of right ventricular dysfunction (RVD) or positive cardiac biomarkers. Low-risk patients are defined as being haemodynamically stable with no evidence of RVD or abnormal cardiac biomarkers [3]. IQR: interquartile range; PE: pulmonary embolism; TTE: transthoracic echocardiogram.

    • TABLE 2

      Subgroup analysis showing the difference between study design for the studies with combined adverse events, all-cause mortality and pulmonary embolism (PE)-related mortality

      Number of studiesPooled effect size (95% confidence interval)I2 (%)Q statistic
      Combined adverse events
       Prospective193.81 (2.02–7.21)57.20.635
       Retrospective103.04 (2.44–3.80)0
       TTE study143.70 (2.60–5.28)47.10.473
       Non-TTE study152.89 (2.09–3.99)0
       TTE <24 h73.74 (2.38–5.88)54.60.439
       TTE 24–72 h113.03 (1.92–4.77)0
       Outcomes in hospital or <14 days183.43 (2.61–4.49)0.40.574
       Outcomes <30 days113.26 (2.12–5.02)50.7
       Published before 2014 ESC PE guidelines183.56 (2.66–4.76)6.30.383
       Published after 2014 ESC PE guidelines113.07 (2.07–4.54)46.3
       AHRQ study quality fair or poor203.45 (2.54–4.69)15.40.603
       AHRQ study quality good93.13 (2.11–4.65)47.0
      All-cause mortality
       Prospective141.95 (1.56–2.44)00.543
       Retrospective192.48 (1.62–3.81)47.1
       TTE study132.13 (1.74–2.58)00.462
       Non-TTE study112.50 (1.36–4.58)34.1
       TTE <24 h51.95 (0.84–4.54)00.976
       TTE 24–72 h142.00 (1.55–2.58)33.9
       Outcomes in hospital or <14 days142.88 (2.10–3.93)15.90.011
       Outcomes <30 days101.70 (1.35–2.12)0
       Published before 2014 ESC guidelines162.10 (1.68–2.63)00.619
       Published after 2014 ESC guidelines72.06 (1.38–3.08)52.8
       AHRQ study quality fair or poor142.26 (1.58–3.24)38.00.880
       AHRQ study quality good102.06 (1.59–2.67)0
      PE-related mortality
       Prospective133.36 (2.31–4.88)00.103
       Retrospective47.37 (3.30–16.46)0
       TTE study124.79 (2.92–7.86)19.80.452
       Non-TTE study53.01 (1.64–5.54)0
       TTE <24 h55.56 (1.74–17.74)00.696
       TTE 24–72 h74.12 (2.23–7.63)30.8
       Outcomes in hospital or <14 days93.61 (2.04–6.38)00.392
       Outcomes <30 days86.05 (2.96–12.37)49.8
       Published before 2014 ESC guidelines133.07 (2.12–4.45)00.010
       Published after 2014 ESC guidelines412.16 (5.30–27.91)0
       AHRQ study quality fair or poor78.25 (2.98–22.88)36.10.122
       AHRQ study quality good103.32 (2.28–4.85)0

      AHRQ: Agency for Healthcare Research and Quality; ESC: European Society of Cardiology; TTE: transthoracic echocardiogram.

      Supplementary Materials

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        Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

        Supplementary material ERR-0120-2022.SUPPLEMENT

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      Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis
      Graeme Prosperi-Porta, Paul Ronksley, Omid Kiamanesh, Kevin Solverson, Pouya Motazedian, Jason Weatherald
      European Respiratory Review Dec 2022, 31 (166) 220120; DOI: 10.1183/16000617.0120-2022

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      Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis
      Graeme Prosperi-Porta, Paul Ronksley, Omid Kiamanesh, Kevin Solverson, Pouya Motazedian, Jason Weatherald
      European Respiratory Review Dec 2022, 31 (166) 220120; DOI: 10.1183/16000617.0120-2022
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