Clinical research study
Enlarged Right Ventricle Without Shock in Acute Pulmonary Embolism: Prognosis

https://doi.org/10.1016/j.amjmed.2007.06.032Get rights and content

Abstract

Objective

An unsettled issue is the use of thrombolytic agents in patients with acute pulmonary embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement.

Methods

Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography.

Results

Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk = 1.04).

Conclusion

In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.

Section snippets

Materials and Methods

Data are from the PIOPED II, which was a multicenter national collaborative investigation of the accuracy of multidetector computed tomographic (CT) angiography alone with venous phase imaging of the veins of the pelvis and thigh for the diagnosis of acute PE.6 The data allow a retrospective cohort comparison of outcome between those with and those without RV enlargement. In PIOPED II, 181 patients had a reference test diagnosis of PE and a CT angiogram that was of adequate quality for

Results

Among 160 patients with PE, by the reference standard in PIOPED II who had a CT angiogram adequate for interpretation of whether PE was present and whose images were available for review for this study, 157 (98%) showed the left and right ventricles with adequate clarity for evaluation of the diastolic dimensions (Figure 3). Two of these received thrombolytic therapy. One of these patients was normotensive but was treated with thrombolytic therapy because of the perceived high risk of RV

Discussion

The data do not support the hypothesis that an enlarged right ventricle in stable patients with acute PE may lead to a higher in-hospital mortality or higher rate of life-threatening adverse events. There was no difference in the rate of death from PE or all-cause mortality between patients with RV enlargement and patients without RV enlargement. In the patients with no prior cardiopulmonary disease, those with possible prior RV enlargement were excluded. None of the patients with RV

Conclusions

In-hospital prognosis is good in patients with PE and RV enlargement, providing they are not in shock, acutely ill, or receiving ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. In patients with PE, RV enlargement alone does not seem to adversely affect prognosis or be an indication for thrombolytic therapy.

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    This study was supported by Grants HL63899, HL63928, HL63931, HL63940, HL63981, HL63982, and HL67453 from the U.S. Department of Health and Human Services, Public Health Services, National Heart, Lung, and Blood Institute, Bethesda, Md.

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