A five-year, single-centre experience on ultrasound-assisted, catheter-directed thrombolysis in patients with pulmonary embolism at high risk and intermediate to high risk.

AIMS: In this single-centre study, we aimed to evaluate the short- and long-term efficacy and safety outcomes of ultrasound-assisted thrombolysis (USAT) performed in patients with acute pulmonary embolism (PE) at intermediate to high risk and high risk (IHR, HR). METHODS AND RESULTS: The study group comprised 141 retrospectively evaluated patients with PE who underwent USAT. Tissue-type plasminogen activator (t-PA) dosage was 36.1±15.3 mg, and infusion duration was 24.5±8.1 hours. USAT was associated with improvements in echocardiographic measures of right ventricle systolic function, pulmonary arterial (PA) obstruction score, right to left ventricle diameter ratio (RV/LV), right to left atrial diameter ratio and PA pressures, irrespective of the risk (p<0.0001 for all). In-hospital mortality, major and minor bleeding rates were 5.7%, 7.8% and 11.3%, respectively. Follow-up data (median 752 days) were available in all patients. Absolute and % changes in RV/LV and % changes in PA mean pressure were significantly higher in patients younger than 65 years compared with older patients, whereas bleeding, 30-day and long-term mortality were not related to age, t-PA dosage or infusion duration. HR versus IHR increased 30-day mortality. CONCLUSIONS: USAT was associated with improvements in thrombolysis and stabilisation of haemodynamics along with relatively low rates of complications in patients with PE, regardless of the risk status. However, HR still confers a higher short-term mortality. Increasing the t-PA dosage and prolongation of infusion may not offer benefit in USAT treatments.

Reappraisal of the reliability of Doppler echocardiographic estimations for mean pulmonary artery pressure in patients with pulmonary hypertension: a study from a tertiary centre comparing four formulae.

Different Doppler echocardiography (DE) models have been proposed for estimation of mean pulmonary arterial pressures (PAMP) from tricuspid regurgitation (TR) jet velocity. We aimed to compare four TR-derived DE models in predicting the PAMP measured by right heart catheterization (RHC) in different groups of precapillary pulmonary hypertension (PH). A total of 287 patients with hemodynamically pre-capillary PH were enrolled (mean age = 51 ± 17.4 years, 59.9% female). All patients underwent DE before RHC (< 3 h) and four formulae (F) were used for TR-derived PAMP estimation (PAMP-DE). These were as follows: F1 = Chemla (0.61 × systolic pulmonary artery pressure [PASP] + 2); F2 = Friedberg (0.69 × PASP - 0.22), F3 = Aduen (0.70 × PASP); and F4 = Bech-Hanssen (0.65 × PASP - 1.2). The PASP and PAMP (mmHg) measured by RHC were 89.1 ± 30.4 and 55.8 ± 20.8, respectively. In the overall PH group, DE estimates for PASP (r = 0.59, P = 0.001) and PAMP (r = 0.56, P = 0.001 for all) showed significant correlations with corresponding RHC measures. Concordance was noted between Chemla and Bech-Hanssen, and Aduen and Bech-Hanssen. The Bland-Altman plot showed that Chemla and Bech-Hanssen overestimated and Friedberg and Aduen underestimated PAMP-RHC measures. Paired-t test showed significant systematic biases for Aduen and Bech-Hanssen while Passing-Bablok non-parametric analysis revealed significant systematic biases all four PAMP-DE estimates. There was poor agreement between PAMP-RHC measures and PAMP-DE deciles (Kappa values were 0.112, 0.097, 0.095, and 0.121, respectively). This study showed a poor agreement between PAMP-DE estimates by four TR-derived formulae and PAMP-RHC in patients with PH, regardless of the etiology. However, these results can not be fully extrapolated to a normal population and did not address the reliability of DE estimates for PH screening procedures.

Extrinsic compression of left main coronary artery by aneurysmal pulmonary artery in severe pulmonary hypertension: its correlates, clinical impact, and management strategies.

Aims: Although left main coronary artery (LMCA) compression (Co) by pulmonary artery (PA) aneurysm (A) has been reported in some pulmonary hypertension (PH) series, clinical importance and management of this complication remain to be determined. In this single-centre prospective study, we evaluated correlates, clinical impact, and management strategies of LMCA-Co in patients with PH. Methods and results: Our study group comprised 269 (female 166, age 52.9 ± 17.3 years) out of 498 patients with confirmed PH who underwent coronary angiography (CA) because of the PAA on echocardiography, angina or incidentally detected LMCA-Co during diagnostic evaluation with multidetector computed tomography. The LMCA-Co ≥ 50% was documented in 22 patients (8.2%) who underwent CA, and stenosis were between 70% and 90% in 14 of these. Univariate comparisons revealed that a younger age, a D-shaped septum, a higher PA systolic, diastolic, and mean pressures and pulmonary vascular resistance, a larger PA diameter, a smaller aortic diameter and pulmonary arterial hypertension associated with patent-ductus arteriosus, atrial or ventricular septal defects were significantly associated with LMCA-Co. Bare-metal stents were implanted in 12 patients and 1 patient underwent PAA and atrial septal defect surgery and another one declined LMCA stenting procedure. Conclusion: Our study demonstrates that LMCA-Co is one of the most important and potentially lethal complications of severe PH, and alertness for this risk seems to be necessary in specific circumstances related with PAA. However, long-term benefit from stenting in this setting remains as a controversy.

Ultrasound-Assisted Catheter-Directed Thrombolysis in High-Risk and Intermediate-High-Risk Pulmonary Embolism: A Meta-Analysis.

BACKGROUND: Catheter-directed Ultrasound-Assisted Thrombolysis (USAT) is a novel technology providing a high efficacy with a reduced bleeding risk in patients with pulmonary embolism (PE). METHODS: We performed a meta-analysis based on presented or published PE series in which USAT was utilized. We searched the MEDLINE, EMBASE and the Cochrane Library for trials published up to December 2015. RESULTS: The primary outcomes were mean pulmonary artery pressure (PAMP), right to left ventricle diameter ratio (RV/LV ratio) and computed tomography (CT) obstruction score. The secondary outcomes were all-cause and cardiovascular mortality, major and minor bleeding episodes and recurrent PE. The 11 trials (n=553) and 15 trials (n=655) met eligibility criteria of primary and secondary outcomes, respectively. USAT was found to significantly reduce PAMP, RV/LV ratio and CT obstruction scores. After adjusting for baseline covariates in meta-regression analysis, male sex and number of high-risk patients were found to be associated with PAMP and RV/LV ratio while only male sex was associated with CT obstruction scores. The pooled incidence of all-cause and cardiovascular mortality were 3.2% and 2.2%, and the incidence of major and minor bleeding episodes were 5.5% and 6.9%, respectively. In the pooled analysis of the remaining trials, the incidence of recurrent PE was 1.7%. USAT compared with three randomized thrombolytic trials showed a similar death rate with a lower rate of major bleeding. CONCLUSION: This meta-analysis confirmed that USAT significantly reduced PAMP, RV/LV ratio and CT obstruction scores with similar death rates and a lower risk of major bleeding compared with patients with PE undergoing systemic thrombolytic treatment.

Ultrasound-Assisted Catheter-Directed Thrombolysis in High-Risk and Intermediate-High-Risk Pulmonary Embolism: Results From a Single-Center Cohort.

We present our single-center results on ultrasound-assisted thrombolysis (USAT) in patients with pulmonary embolism (PE) at intermediate high risk (IHR) and high risk (HR). Our study consisted of 75 patients with PE who underwent USAT (60 at IHR and 15 at HR). The median time delay from symptoms to USAT was 5 days. Ultrasound-assisted thrombolysis resulted in improvements in tricuspid annular plane systolic excursion; pulmonary artery (PA) systolic and mean pressures; Qanadli score; right to left ventricle diameter ratio and right to left atrial diameter ratio; and diameters of main, right, and left PA regardless of the baseline risk status ( P < .0001 for all). Death was documented in 4 patients, and major and minor bleeding were noted in 2 and 5 of the patients, respectively. No PE-related event was noted during postdischarge follow-up period of median 310 days. Our study revealed that USAT facilitates the resolution of PA thrombotic burden, recovery of pulmonary hemodynamics, and right heart functions with acceptable rates of procedure-related complications in patients with PE, irrespective of the IHR or HR status.

Relationship of neutrophil-lymphocyte ratio with the presence, severity, and extent of coronary atherosclerosis detected by coronary computed tomography angiography.

We evaluated whether the neutrophil-lymphocyte ratio (NLR) was associated with the presence, severity, and extent of coronary atherosclerotic plaques detected by computed tomography angiography (CTA). We studied 238 patients who underwent dual-source 64-slice CTA for the assessment of coronary artery disease. Coronary arteries were evaluated on 16-segment basis and critical plaque was described as luminal narrowing >50%. In regression analysis, being in the third NLR tertile increased the risk of coronary atherosclerosis (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.15-4.43; P = .023). When the severity of coronary atherosclerosis was assessed, being in the third NLR tertile increased the risk of critical luminal stenosis (OR, 2.60; 95% CI, 1.19-5.69; P = .017). Although plaque morphology was not associated with NLR, the extent of coronary atherosclerosis was increased with higher NLR tertiles (P = .001). Our results suggest that a higher NLR may be a useful additional measure to assess cardiovascular risk in clinical practice.