Should Transesophageal Echocardiography Become a Routine Test in Patients with Suspected Pulmonary Thromboembolism?

Pulmonary thromboembolism presents in two clinical subsets: acute pulmonary embolism (PE) with or without right heart thrombi or paradoxical embolism and chronic thromboembolic pulmonary hypertension (CTEPH). Both PE and CTEPH have been underdiagnosed and carry high mortality rates. Acute massive PE is a hemodynamic entity leading to right ventricular overload readily identified with the use of transthoracic echocardiography. Transesophageal echocardiography (TEE) is a noninvasive bedside technique that has high diagnostic accuracy for the detection of central pulmonary thromboembolism. Due to the high prevalence of central pulmonary thromboembolism in acute PE, TEE is a useful method to provide the necessary proof for the institution of thrombolytic therapy. In the subset of patients with acute PE combined with right heart thrombi or paradoxical embolism, TEE is the technique of choice to guide surgery. CTEPH presents as primary pulmonary hypertension, but it has become a surgically curable disease. TEE is a fast, fairly sensitive, and highly specific diagnostic bedside modality to select surgical candidates with CTEPH. TEE should become a routine test in patients with suspected massive acute PE, suspected right heart thrombi, or paradoxical embolism associated with acute pulmonary embolism and in patients with primary pulmonary hypertension to select those having CTEPH who are suitable for surgery.     

The role of transesophageal echocardiography in the management of patients with acute and chronic pulmonary thromboembolism

Acute and chronic pulmonary thromboembolism carry high mortality. The role of transesophageal echocardiography (TEE), however, has not been well delineated in patients with suspected pulmonary thromboembolism. The aim of the present study was to demonstrate the value of Tee in patients with various clinical manifestations of pulmonary thromboembolic disease. Twelve patients--ten males and two females, age 47-85 years--are presented in whom central pulmonary thromboembolism was found by TEE. Six patients were referred for breathlessness and had moderate to severe pulmonary hypertension (PH) with (3) or without (1) right atrial thrombus or had right heart dilatation (1) or right ventricular myxoma (1) on transthoracic echocardiography (TTE). Thrombolysis (2), surgery (2), and heparin (2) treatment was performed without angiography. All but one patient recovered. Six patients had severe PH by TTE, one of them had a right atrial thrombus. Angiography was done in five patients in whom surgery was considered. Pulmonary thromboendarterectomy was successfully performed in two patients, it was contraindicated in two patients for advanced age or severe left ventricular dysfunction, both patients died during follow-up, and two patients were waiting for surgery. In conclusion: TEE has a definite role in the management of patients with acute pulmonary thromboembolism or in pulmonary embolism associated with right-sided intracardiac masses and in the selection of patients with PH for pulmonary thromboendarterectomy.     

Catheter ablation of atrial fibrillation facilitated by preprocedural three-dimensional transesophageal echocardiography: Long-term outcome

AIM To evaluate the long-term outcome of catheter ablation of atrial fibrillation(AF) facilitated by preprocedural threedimensional(3-D) transesophageal echocardiography.METHODS In 50 patients, 3D transesophageal echocardiography(3D TEE) was performed immediately prior to an ablation procedure(paroxysmal AF: 30 patients, persistent AF: 20 patients). The images were available throughout the ablation procedure. Two different ablation strategies were used. In most of the patients with paroxysmal AF, the cryoablation technique was used(Arctic Front Balloon, Cryo Cath Technologies/Medtronic; group A2). In the other patients, a circumferential pulmonary vein ablation was performed using the CARTO system [Biosense Webster; group A1(paroxysmal AF), group B(persistent AF)]. Success rates and complication rates were analysed at 4-year follow-up.RESULTS A 3D TEE could be performed successfully in all patients prior to the ablation procedure and all four pulmonaryvein ostia could be evaluated in 84% of patients. The image quality was excellent in the majority of patients and several variations of the pulmonary vein anatomy could be visualized precisely(e.g., common pulmonary vein ostia, accessory pulmonary veins, varying diameter of the left atrial appendage and its distance to the left superior pulmonary vein). All ablation procedures could be performed as planned and almost all pulmonary veins could be isolated successfully. At 48-mo followup, 68.0% of all patients were free from an arrhythmia recurrence(group A1: 72.7%, group A2: 73.7%, group B: 60.0%). There were no major complications.CONCLUSION3 D TEE provides an excellent overview over the left atrial anatomy prior to AF ablation procedures and these procedures are associated with a favourable long-term outcome.     

Visualization of the central pulmonary arteries by biplane transesophageal echocardiography

It is suggested that transesophageal echocardiography (TEE), by detecting thromboemboli in the proximal parts of the pulmonary arteries, is useful in the diagnosis of pulmonary embolism. However, the data on visualization of the pulmonary arteries are limited. The extent of the pulmonary arteries that can be precisely visualized during biplane TEE was assessed in 51 consecutive patients (23 female, 28 male, aged 56.6±12.5 years) without structural heart disease. The main pulmonary artery and the right pulmonary artery were detected in 96.1% and 94.1% of patients, respectively. Although the proximal part of the left pulmonary artery was found in only 47.0% of patients, its distal part was visualized in 92.2%. During TEE, proximal parts of the lobar arteries on both sides were visualized in 88.2% of patients. Thus, the central pulmonary arteries including proximal parts of the lobar branches can be precisely visualized by biplane TEE in the majority of patients. Only the proximal part of the left pulmonary artery is difficult to assess.     

Transesophageal echocardiographic monitoring of percutaneous mitral balloon valvulotomy.

This study was designed to evaluate the usefulness of performing transesophageal echocardiography (TEE) during percutaneous mitral balloon valvulotomy (PMBV). TEE was performed in 35 consecutive patients with symptomatic severe mitral stenosis during PMBV (group A). Another group of 27 patients with mitral stenosis who underwent PMBV without TEE was used for comparison (group B). TEE was most helpful in guiding transseptal puncture, aiding in proper positioning of the balloon during the dilatation procedure and enabling early detection of complications. The results show that PMBV when aided by TEE has a tendency to decrease the frequency of significant mitral regurgitation without compromising the final mitral valve area. TEE decreased the x-ray exposure time and was well-tolerated. Thus, TEE provides information that makes this interventional catheterization procedure safer and easier to perform.     

Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation

Background:

Pulmonary artery (PA) catheter provides a variety of cardiac and hemodynamic parameters. In majority of the patients, the catheter tends to float in the right pulmonary artery (RPA) than the left pulmonary artery (LPA). We evaluated the location of PA catheter with the help of transesophageal echocardiography (TEE) to know the incidence of its localization. Three views were utilized for this purpose; midesophageal ascending aorta (AA) short-axis view, modified mid esophageal aortic valve long-axis view, and modified bicaval view.

Methods:

We enrolled 135 patients undergoing elective cardiac surgery where both the PA catheter and TEE were to be used; for this prospective observational study. PA catheter was visualized by TEE in the above mentioned views and the degree of clarity of visualization by three views was also noted. Position of the PA catheter was further confirmed by a postoperative chest radiograph.

Results:

One patient was excluded from the data analysis. PA catheter was visualized in RPA in 129 patients (96%) and in LPA in 4 patients (3%). In 1 patient, the catheter was visualized in main PA in the chest radiograph. The midesophageal AA short-axis, modified aortic valve long-axis, and modified bicaval view provided good visualization in 51.45%, 57.4%, and 62.3% patients respectively. Taken together, PA catheter visualization was good in 128 (95.5%) patients.

Conclusion:

We conclude that the PA catheter has a high probability of entering the RPA as compared to LPA (96% vs. 3%) and TEE provides good visualization of the catheter in RPA.     

Transesophageal echocardiography-guided cardioversion of atrial fibrillation. Selection of a low-risk group for immediate cardioversion.

INTRODUCTION: In patients (pts) with atrial fibrillation (AF) of more than 48 hours' duration, electrical cardioversion (ECV) should only be performed after 3 weeks of effective anticoagulation. Transesophageal echocardiography (TEE) allows earlier ECV; however, despite exclusion of thrombi in the atrium and left atrial appendage (LAA), cases of thromboembolism related to ECV have been documented in AF. To define a low-risk group for cardioversion without previous anticoagulation, pts were selected for immediate ECV if no thrombi or dynamic spontaneous echo contrast (auto-contrast) were found after TEE and if LAA velocity was more than 0.25 m/sec. METHODS AND RESULTS: We performed TEE in 31 consecutive pts referred for ECV for AF of more than 48 hours' duration and without previous anticoagulation. After TEE the pts eligible for immediate ECV began anticoagulation with low molecular weight heparin (enoxaparin), subcutaneously in therapeutic doses, together with warfarin immediately before cardioversion. Enoxaparin was continued until an INR of over 2 was reached. Based on the TEE findings, the pts were divided in 2 groups: immediate ECV, group A, 20 pts with a mean age of 62 +/- 13 years, 6 female; and conventional therapy with warfarin before ECV, group B, 11 pts, mean age of 67 +/- 10 years (p < 0.05), 2 female. None of the pts in either group had mitral stenosis or previous episodes of thromboembolism. The mean transverse diameter of the left atrium in the 31 pts was 47 +/- 4.5 mm, without statistically significant differences between the 2 groups. Of the 11 pts in group B, 3 had a thrombus in the LAA, 6 dynamic spontaneous echo contrast and the remainder LAA velocities of less than 0.25 m/sec. ECV was achieved in all the pts, with no complications. Oral anticoagulation was maintained for at least a month. At one month, sinus rhythm was maintained in 75% of group A and 45% of group B (p < 0.01). CONCLUSION: In pts with AF of more than 48 hours' duration and no previous history of thromboembolism, the use of our exclusion criteria during TEE enabled stratification of a low-risk population for immediate ECV, which was accomplished effectively and safely in 2/3 of the pts. This strategy is associated with early symptomatic improvement, and may contribute to maintenance of sinus rhythm after one month, which was significantly better than in the pts who had prolonged therapy with warfarin before ECV, despite the differences found in age and left ventricular function.     

非瓣膜病心房颤动患者血浆D-二聚体与左房功能异常的关联性及对其诊断价值

目的:以经食道心脏超声(transesophageal echocardiography,TEE)为判断标准,分析非瓣膜病持续性心房颤动患者血浆D-二聚体水平与左房功能异常的关联性及其对左房功能异常的诊断价值。方法:52例持续性心房颤动患者,病因排除瓣膜性心脏病。依据TEE结果分为两组:左房功能异常组(栓塞高危组,n=17);其余患者为左房功能正常(对照组,n=35)。单因素分析比较两组间基础临床资料、经胸超声(TTE)结果和凝血指标,多因素Logistics回归分析栓塞高危患者的危险因素并按诊断试验评价方法计算真实性指标。结果:栓塞高危组和对照组在年龄、既往栓塞史、左房内径、左室射血分数、血浆D-二聚体水平方面差异具有显著性(均P0.05)。Logistics回归分析,仅左室射血分数(P0.05)和血浆D-二聚体浓度(P0.01)是栓塞高危状态的相关因素。以300μg/L为阈值,D-二聚体诊断左心房功能异常的灵敏度为88%,特异度为83%,准确度为85%。结论:非瓣膜病持续性心房颤动患者外周血液D-二聚体水平与左房功能异常(栓塞高危状态)有关联,它对左房功能异常有一定诊断价值。     

Evaluation of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma

AIM:To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed.METHODS:The study population consisted of 36 patients with obstructive jaundice caused by hepatocellular carcinoma(HCC)who underwent endoscopic biliary stenting(EBS)as the initial drainage procedure at our hospital.The EBS technical success rate and drainage success rate were assessed.Drainage was considered effective when the serum total bilirubin level decreased by 50%or more following the procedure compared to the pre-drainage value.Survival time after the procedure and patient background characteristics were assessed comparatively between the successful drainage group(group A)and the non-successful drainage group(group B).The EBS stent patency duration in the successful drainage group(group A)was also assessed.RESULTS:The technical success rate was 100%for both the initial endoscopic nasobiliary drainage and EBS in all patients.Single stenting was placed in 21 patients and multiple stenting in the remaining 15 patients.The drainage successful rate was 75%and the median interval to successful drainage was 40 d(2-295 d).The median survival time was 150 d in group A and 22 d in group B,with the difference between the two groups being statistically significant(P<0.0001).There were no statistically significant differences between the two groups with respect to patient background characteristics,background liver condition,or tumor factors;on the other hand,the two groups showed statistically significant differences in patients without a history of hepatectomy(P=0.009)and those that received multiple stenting(P=0.036).The median duration of stent patency was 43 d in group A(2-757 d).No early complications related to the EBS technique were encountered.Late complications occurred in 13 patients(36.1%),including stent occlusion in 7,infection in 3,and distal migration in 3.CONCLUSION:EBS is recommended as the initial drainage procedure for obstructive jaundice caused by HCC,as it appears to contribute to prolongation of survival time.     

Utility of transesophageal echocardiography in identification of thrombogenic milieu in patients with atrial fibrillation (an ACUTE ancillary study)

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of >2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >/=1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p <0.001) for identification of risk. Thus, in addition to thrombus identification, TEE has significant incremental value in the identification of patients who had high thromboembolic risk. In conclusion, this study supports the role of TEE and anticoagulation monitoring in patients who have atrial fibrillation and is useful for identifying thromboembolic risk factors.     

Ultrafast three-dimensional contrast-enhanced magnetic resonance angiography and imaging in the diagnosis of partial anomalous pulmonary venous drainage

OBJECTIVES: The purpose of our study was to evaluate patients with suspected anomalous pulmonary veins (APVs) and atrial septal defects (ASDs) using fast cine magnetic resonance imaging (MRI) and ultrafast three-dimensional magnetic resonance angiography (MRA). BACKGROUND: Precise anatomic definition of anomalous pulmonary and systemic veins, and the atrial septum are prerequisites for surgical correction of ASDs. Cardiac catheterization and transesophageal echocardiography (TEE) are currently used to diagnose APVs, but did not provide complete information in our patients. METHODS: Twenty consecutive patients with suspected APVs were studied by MRA after inconclusive assessment by catheterization, TEE or both. The MRI images were acquired with a fast cine sequence and a novel ultrafast three-dimensional sequence before and after contrast injection. RESULTS: Partial anomalous pulmonary venous drainage was demonstrated in 16 of 20 patients and was excluded in four patients. Magnetic resonance imaging correctly diagnosed APVs and ASDs in all patients (100%) who underwent surgery. For the diagnosis of APVs, the MRI and catheterization results agreed in 74% of patients and the MRI and TEE agreed in 75% of patients. For ASDs, MRI agreed with catheterization and TEE in 53% and 83% of patients, respectively. CONCLUSIONS: Fast cine MRI with three-dimensional contrast-enhanced MRA provides rapid and comprehensive anatomic definition of APVs and ASDs in patients with adult congenital heart disease in a single examination.     

Assessment of atrial pathologies in children using transesophageal echocardiography]

OBJECTIVE: Transesophageal echocardiography (TEE) is indicated for suspected atrial septal pathology and for monitoring of interventional procedures such as an atrial septal defect (ASD) closure during cardiac catheterization. Transesophageal echocardiography also helps to demonstrate postoperative complications and residual defects of complex congenital cardiac anomalies. METHODS: Transesophageal echocardiography was performed in 112 pediatric patients with or suspected atrial pathology at our institution between 1999-2002, using the standard techniques. The mean age was 8.7+/-4.2 years. RESULTS: In 45 of 112 children the suspected atrial defects were confirmed with the TEE. Patent foramen ovale was correctly predicted in 13.4% of patients by TEE, but only in 8.7% of patients by echocardiography. Multiple ASD's were correctly defined in 4.1%, and high venosus defects were documented in 6.1% of children by the TEE. We used TEE in 13% of patients for detecting atrial vegetations in patients with possible endocarditis, and evaluation of the postoperative care of atrial surgery such as Fontan or Senning operations and total correction of abnormal pulmonary venous return. Successful transcatheter closure of 7 ASD's was accomplished under TEE guidance. CONCLUSION: Transesophageal echocardiography allows a much more detailed evaluation of atrial morphology than transthoracic echocardiography even in infants. Transesophageal echocardiography is also indicated during interventional procedures and postoperative evaluation of the atrial pathology.     

Right atrial spontaneous echo contrast indicates a high incidence of perfusion defects in pulmonary scintigraphy in patients with atrial fibrillation

This study investigated the relationship between right atrial SEC (RA-SEC) and silent pulmonary embolism (PE) in patients with nonvalvular atrial fibrillation (NVAF). Spontaneous echo contrast (SEC) within the cardiac chambers is associated with an increased risk of thromboembolism. However, most studies have examined the relationship between left atrial SEC and systemic thromboembolic disease. Transesophageal echocardiography (TEE) was performed in 210 patients with NVAF to assess a risk of thromboembolism. Right atrial SEC was detected in 37 patients, and 35 of these patients with RA-SEC and 29 patients without RA-SEC were enrolled in this study. However, patients with a history of symptomatic PE or deep vein thrombosis were excluded. Spontaneous echo contrast was diagnosed by TEE as the presence of smokelike echoes that swirled in a circular pattern. PE was diagnosed by pulmonary scintigraphy. Thrombotic and thrombolytic parameters, including serum concentrations of plasmin-α-plasmin inhibitor complex (PIC), thrombin-antithrombin complex (TAT), D-dimer, and fibrinogen were measured in all patients. Left ventricular dimension, cardiac function, and hematologic parameters were similar in the two groups. Nevertheless, the incidence of perfusion defects in pulmonary scintigraphy was significantly higher in the group with RA-SEC (40%) than in the group without RA-SEC (7%; chi-square, P = 0.006). The increased incidence of perfusion defects in pulmonary scintigraphy in patients with RA-SEC indicates that right atrial SEC may be a predictable factor at a high risk of PE.     

Transesophageal echocardiography in the intensive care unit: Impact on diagnosis and decision-making

Transesophageal echocardiography (TEE) is widely used in the management of patients in intensive care units. The present study assesses the specific value of this technique in various categories of these patients. We reviewed 113 studies performed in 100 such patients for: suspected aortic dissection (25), suspected endocarditis (33), source of emboli assessment (19), hemodynamic instability (15), and miscellaneous (21). TEE provided diagnostic information in all patients with aortic dissection, in 53% of the cases with hemodynamic instability, in 50% of the cases with septic states with high likelihood of endocarditis, and in 29% of the cases where the question was the source of emboli. When the clinical probability for endocarditis was low, all transesophageal echocardiograms performed in septic patients were negative. The information provided by TEE was considered crucial in one-third of the positive cases; in about one-half of these special cases, the results were instrumental for further surgical management. There were no significant side effects related to the procedure. TEE is easily performed in the intensive care unit setting and yields useful information in almost half of the cases. Special benefit is expected in suspected aortic disease, hemodynamic instability, suspected endocarditis, and embolic events. The overall yield as screening procedure in febrile patients is low.     

Radionuclide techniques in early diagnosis of pulmonary artery thromboembolism

A combined procedure of indirect radionuclide phlebography and emission tomography of the lung with human serum albumin microspheres was employed to diagnose thromboembolism of pulmonary arterial branches (TPAB) and thrombosis in the inferior cava system. Four hundred and forty nine patients suspected for TPAB were examined. The data characteristic of pulmonary thromboembolism were obtained in 21.6% of cases. In 75 (17.6%) of 432 patients, indirect radionuclide phlebography revealed signs of thrombosis in the inferior cava at various sites. The radionuclide study of pulmonary perfusion is the only technique that assesses the degree of recovery of pulmonary perfusion after TPAB.     

Transesophageal echocardiography in an emergency setting. A district general hospital experience.

Transesophageal echocardiography is an extremely useful technique for the study of various cardiovascular pathologies. In the particular setting of emergency, it is of great value for prompt diagnosis and appropriate therapy. It was our aim to evaluate, in our hospital, the benefits obtained by the use of transesophageal echocardiography in an emergency setting. We retrospectively studied patients who underwent transesophageal echocardiography (TEE) in an emergency setting, from June 1997 to December 2002, evaluating demographic characteristics, indication to perform TEE, benefit obtained (diagnosis or exclusion of initial diagnosis), and technique-related complications. There were 97 transesophageal echocardiograms performed in an emergency setting in the period under consideration, accounting for 19.3% of the total number of exams. Fifty-two patients (53.6%) were male, mean age 63.9 +/- 12.7. Nineteen patients (19.6%) were on assisted ventilation. The indications to perform TEE were: possible massive or submassive pulmonary thromboembolism in 32 patients (33.0%); suspected aortic dissection in 19 (19.6%); shock with inconclusive transthoracic echocardiogram in ten (10.3%); possible endocarditis in eight (8.2%); possible prosthetic valve dysfunction in seven (7.2%); intracardiac mass in six (6.2%); search for cardiac source of embolism in five (5.2%); possible mechanical complication of acute myocardial infarction in four (4.1%); pre-electrical cardioversion study in four patients with atrial fibrillation (4.1%); and suspected congenital heart disease in two (2.1%). TEE examination yielded additional information and helped in the therapeutic decision in 88 patients (90.7%), leading to a diagnosis in 49 (50.6%), which was different from the initial diagnostic hypothesis in four, and exclusion of the suspected diagnosis in 39 (40.1%). There was only one minor complication (1.0%) and no TEE-related mortality. We concluded that transesophageal echocardiography is an extremely useful and safe cardiovascular diagnostic technique in an emergency setting in a district general hospital, enabling a diagnosis to be reached or excluded in almost all patients, which is essential for implementing appropriate therapy.     

肺静脉开口面积及左心房容积指数与房颤患者血栓栓塞风险的相关性研究

目的：探讨肺静脉开口面积及左心房容积指数与房颤患者血栓栓塞风险的相关性。方法连续纳入206例非瓣膜性房颤患者,计算 CHADS2评分和 CHA2 DS2-VASc 评分,将评分为0分、1分和≥2分者分别归入低危组、中危组、高危组。根据经食管超声心动图和脑 CT 检查结果,将所有患者分为血栓组和非血栓组。应用肺静脉多层螺旋 CT（multi-slice spiral com-puted tomography,MSCT）测量左上肺静脉、左下肺静脉、右上肺静脉及右下肺静脉的开口面积;运用经胸心脏彩色多普勒超声测量左心房上下径、前后径及左右径,计算左心房容积指数（left atrial volume index,LAVI）。采用 Spearman 等级相关性分析,分析肺静脉开口面积及 LAVI 与血栓栓塞风险计分的相关性,通过 ROC 曲线比较各项指标对非瓣膜性房颤患者血栓栓塞的预测价值。结果（1）CHADS2评分低危、中危、高危患者分别有73例（35．4％）、82例（39．8％）和51例（24．8％）,而在 CHA2 DS2-VASc 评分下,各组分别有41例（19．9％）、67例（32．5％）和98例（47．6％）。LAVI、左上肺静脉开口面积、左下肺静脉开口面积、右上肺静脉开口面积、肺静脉开口总面积与 CHADS2评分及 CHA2 DS2-VASc 评分均存在显著相关性。（2）LAVI、左上肺静脉开口面积、左下肺静脉开口面积及肺静脉开口总面积对非瓣膜性房颤患者血栓栓塞风险的预测有诊断价值。结论心脏超声测得的 LAVI、MSCT 测得的肺静脉开口面积与CHADS2评分及 CHA2 DS2-VASc 评分存在相关性。这些指标对非瓣膜性房颤患者血栓栓塞风险具有一定的预测价值。     

A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism

OBJECTIVES: Diagnostic strategies in patients with suspected pulmonary embolism have been extensively studied in outpatients; their value in hospitalized patients has not been well established. Our aim was to determine the safety and clinical utility of a simple diagnostic strategy in hospitalized patients with suspected pulmonary embolism. DESIGN: Prospective management study. SETTING: Twelve teaching hospitals (five academic, seven general hospitals). SUBJECT: A total of 605 hospitalized patients with clinically suspected pulmonary embolism. All patients completed the study. INTERVENTIONS: First the clinical decision rule (CDR)-score was calculated. An unlikely CDR-score in combination with a normal D-dimer excluded pulmonary embolism. All other patients underwent helical computed tomography (CT). CT either diagnosed or excluded pulmonary embolism, in which case anticoagulants were started or withheld. All patients were instructed to report symptoms of venous thrombosis. Objective tests were performed to confirm venous thromboembolism. The primary outcome was the incidence of symptomatic venous thrombosis during 3-month follow-up. RESULTS: The combination of an unlikely CDR-score and a normal D-dimer excluded pulmonary embolism in 60 patients (10% of all patients); no venous thromboembolic event occurred during follow-up (0%; 95% CI 0-6.7%). CT excluded pulmonary embolism in 380 patients; during follow-up venous thromboembolism occurred in five patients (1.4%; 95% CI 0.4-3.1%). CONCLUSIONS: An unlikely CDR-score in combination with a normal D-dimer appears to exclude pulmonary embolism safely in hospitalized patients. Before clinical implementation it is important this safety is confirmed by others. CT testing was obviated in only 10% of patients. CT can safely exclude pulmonary embolism in hospitalized patients.     

Prevalence of duplex ultrasonography detectable venous thrombosis in patients with suspected or acute pulmonary embolism

OBJECTIVES: Duplex ultrasonography performance in detecting embolic foci has not been proven satisfactory compared with phlebography or autopsic findings. In case of suspected pulmonary embolism, the embolic focus is only discovered in 11 to 18% of the cases compared with more than 30% with phlebography. For overt acute pulmonary embolism, the discovery rate is in the 30 to 45% range versus 70 to 80% with phlebography or autopsy findings. This discrepancy might result from the fact that duplex ultrasonographic explorations are generally limited to the deep collectors at the cruropopliteal level. The purpose of this study was to assess the prevalence of duplex ultrasonography detected venous thrombosis in patients with suspected or acute pulmonary embolism when the exploration includes the entire venous system from the inferior vena cava to the ankles and examines not only the deep collectors but also the muscle and superficial networks.MATERIAL AND METHODS: This study included all patients with suspected pulmonary embolism referred to the emergency unit from January 1, 1995 through December 31, 1998. The patients' hospital files were used to determine the suspected pulmonary embolism population. The acute pulmonary embolism population was defined as the patients whose files contained documented proof of pulmonary embolism (highly probable ventilation/perfusion pulmonary scintigraphy, positive pulmonary angiography, positive proximal angioscan). Thrombosis of the deep venous collectors with or without associated superficial or muscular localization was classed as "deep venous thrombi" and superficial or muscular thrombosis without involvement of the deep collectors was classed as "other venous thrombi". Subpopliteal thrombosis was classed as distal and popliteal or suprapopliteal thrombosis as proximal.RESULTS: The suspected pulmonary embolism group included 352 patients, 118 men and 234 women aged 67.6 +/- 15.4 and 70.8 +/- 20.0 years respectively (m +/- SD). The acute pulmonary embolism group included 60 patients, 17 men and 43 women aged 66.2 +/- 12.5 and 69.7 +/- 16.6 years respectively. Overall prevalence of duplex-ultrasound detected venous thrombosis was 30.4% (107/352) (95%CI: 25.6-35.2) in the suspected pulmonary embolism group and 80% (48/60) (95%CI: 69.9-90.1) in the acute pulmonary embolism group. Deep venous thrombi reaching the collectors and proximal thrombi predominated. Prevalence of "other venous thrombi" and distal venous thrombi were 6.5% (23/352) and 11.4% (40/352) respectively in the suspected pulmonary embolism group and 15.0% (9/60) and 26.7% (16/60) in the acute pulmonary embolism group. The frequency of asymptomatic venous thrombosis of the lower limbs, irrespective of the localization, was 42.1% (45/107) in the suspected pulmonary embolism group and 52.1% (25/48) in the acute pulmonary embolism group.CONCLUSIONS: The prevalence of duplex-ultrasonography detected venous thrombosis in patients with suspected or proven pulmonary embolism found in this series was equivalent to the rates reported in phlebography and autopsy series. The prevalence was higher than usually reported for duplex-ultrasonography studies limited to the cruro-popliteal level. The difference came from the "other venous thrombi" and "distal deep venous thrombi" discovered by exploring the superficial and muscular networks and the calves. This study demonstrates the contribution of duplex-ultrasonography to the diagnostic strategy for pulmonary embolism.     

Multidetector-row computed tomography management of acute pulmonary embolism.

BACKGROUND: The purpose of this study was to evaluate the usefulness and safety of multidetector-row computed tomography (MDCT) pulmonary angiography and indirect venography management of acute pulmonary embolism (PE), including indication for inferior vena cava (IVC) filter. METHODS AND RESULTS: Seventy-one consecutive patients who were clinically suspected of PE and underwent 16-slice MDCT pulmonary angiography and indirect venography were enrolled. Management included indication of IVC filter for patients with extensive deep venous thrombosis (DVT) in submassive or massive PE. A right ventricular to left ventricular short-axis diameter by MDCT>1.0 was judged as submassive PE. All patients were followed for 1 year. MDCT identified 50 patients with venous thromboembolism and 47 patients had acute PE: 4 were judged as massive, 14 as submassive, and 29 as non-massive by MDCT; 3 patients had DVT alone and 7 patients had caval or iliac DVT. Only 1 patient with massive PE and DVT near the right atrium died of recurrence. No other patients died of PE. CONCLUSION: Management based on MDCT pulmonary angiography combined with indirect venography is considered to be safe and reliable in patients with suspected acute PE.