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1.
Medicine (Baltimore) ; 98(48): e17953, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770203

RESUMO

Chronic thromboembolic pulmonary hypertension (CTEPH), a late complication of pulmonary embolism (PE), is associated with high mortality. However, whether the right ventricular (RV) echocardiographic parameters can predict - in the short- and long-term - the development of CTEPH and mortality after PE remains unknown. Herein, we aim to investigate the incidence of CTEPH after acute PE and to evaluate the risk factors of CTEPH. In this retrospective cohort, patients with PE were followed for 10 years for the onset of CTEPH. The screening was initially conducted through echocardiography and confirmed by right heart catheterization. Also, transient and permanent risk factors were identified. Among 358 patients with PE, 8 patients (4%) were subsequently diagnosed with CTEPH at a median time of 36 months and 47 died during the follow-up period. Notably, both short- and long-term RV dilatation, hypertrophy, and increased pulmonary pressure increased the incidence of CTEPH. However, RV echocardiographic parameters failed to differentiate survivors from non-survivors. Instead, malignancy, respiratory, or chronic heart failure was strongly associated with post PE mortality in the multivariable analysis. According to our findings, post PE screening of CTEPH may facilitate early diagnosis and intervention for patients at high risk of developing CTEPH. Also, RV echocardiographic parameters are associated with subsequent CTEPH, but mortality is mainly dependent on underlying comorbidities.


Assuntos
Ecocardiografia/estatística & dados numéricos , Hipertensão Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Disfunção Ventricular Direita/diagnóstico por imagem , Idoso , Doença Crônica , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/mortalidade , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/mortalidade
3.
Mayo Clin Proc ; 94(10): 1960-1973, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31585580

RESUMO

OBJECTIVE: To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE). PATIENTS AND METHODS: Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes. RESULTS: From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P<.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P<.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P<.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P<.001) and II (OR, 0.63; 95% CI 0.58-0.69; P<.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04). CONCLUSION: Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.


Assuntos
Mortalidade Hospitalar , Obesidade/complicações , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Magreza/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida
4.
Int Heart J ; 60(5): 1137-1141, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484878

RESUMO

Current therapeutic methods for chronic thromboembolic pulmonary hypertension (CTEPH) can improve hemodynamic status and are expected to improve prognoses. However, some patients experience dyspnea during effort and continue supplemental oxygenation despite their hemodynamic status being fully improved. Considering the pathogenesis of CTEPH, the dead space and intrapulmonary shunt are assumed to be responsible for hypoxia in CTEPH, but their contributions are unclear. It is also unclear whether they are improved after treatment. The aim of this study was to investigate the implications of the dead space ratio (DSR) and the intrapulmonary shunt ratio (ISR) for hypoxia in CTEPH and treatment for CTEPH.We retrospectively measured the DSR and ISR of 23 consecutive patients with CTEPH. For 11 of these 23 (10 were treated by balloon pulmonary angioplasty, one with riociguat), we also measured these parameters before and after CTEPH treatments. Overall, the DSR and ISR were abnormally elevated (DSR: 0.63 ± 0.06; ISR: 0.20 ± 0.05). After treatment, mean pulmonary artery pressure was improved (from 40.3 ± 8.1 to 25.5 ± 2.7 mmHg). Although atrial oxygen saturation (SaO2), DSR and ISR were improved (SaO2: from 90.2 ± 3.2 to 93.7 ± 1.8%; DSR: from 0.64 ± 0.06 to 0.58 ± 0.05; ISR: from 0.20 ± 0.04 to 0.18 ± 0.02), these improvements were slight compared with that of mean pulmonary artery pressure.The DSR and ISR were abnormally elevated in patients with CTEPH and their improvement by treatment was limited. Only DSR can be a useful marker for normalization of hypoxia in CTEPH.


Assuntos
Angioplastia com Balão/métodos , Hipertensão Pulmonar/terapia , Embolia Pulmonar/terapia , Pirazóis/uso terapêutico , Pirimidinas/uso terapêutico , Espaço Morto Respiratório/efeitos dos fármacos , Adulto , Idoso , Doença Crônica , Feminino , Hemodinâmica/fisiologia , Hospitais Universitários , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/mortalidade , Japão , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/métodos , Prognóstico , Circulação Pulmonar/fisiologia , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Espaço Morto Respiratório/fisiologia , Testes de Função Respiratória , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Taxa de Sobrevida , Resultado do Tratamento
6.
Anatol J Cardiol ; 22(1): 26-32, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31264657

RESUMO

OBJECTIVE: Right ventricular (RV) dysfunction in acute pulmonary embolism (APE) has been associated with increased mortality and morbidity. The aim of the present study was to assess the timing and magnitude of regional RV functions using speckle-tracking echocardiography (STE) and their relationship to early hospital mortality in patients with APE. METHODS: One hundred forty-two patients were prospectively studied at the onset of an acute episode and after a median follow-up period of 30 days. Their clinical and laboratory characteristics were recorded. For all patients, conventional two-dimensional echocardiography and STE were performed within 24 h after the diagnosis of APE. RESULTS: Twenty-eight (19.7%) patients died during the hospitalization follow-up. Patients who died during hospitalization were older and had higher high sensitivity cardiac troponin T levels, and a higher percentage of patients had simplified Pulmonary Embolism Severity Indexes. In STE analyses, they had lower RV free wall peak longitudinal systolic strain (PLSS) and higher RV peak systolic strain dispersion indexes. The time to PLSS difference between RV free wall and LV lateral was longer in patients who died during hospitalization than in those who survived, and this was an independent predictor of early hospital mortality with 85.7% sensitivity and 75.0% specificity in patients with APE. CONCLUSION: APE was associated with RV electromechanical delay and dispersion. Electromechanical delay index might be useful to predict early hospital mortality in patients with APE.


Assuntos
Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Função Ventricular Direita/fisiologia , Doença Aguda , Idoso , Ecocardiografia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Curva ROC
7.
N Engl J Med ; 381(4): 328-337, 2019 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-31259488

RESUMO

BACKGROUND: Whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known. METHODS: In this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met. RESULTS: The median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P = 0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients. CONCLUSIONS: Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.).


Assuntos
Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Ferimentos e Lesões/terapia , Adulto , Angiografia por Tomografia Computadorizada , Humanos , Incidência , Escala de Gravidade do Ferimento , Estimativa de Kaplan-Meier , Perna (Membro)/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/mortalidade , Risco , Falha de Tratamento , Ultrassonografia , Trombose Venosa/diagnóstico por imagem , Ferimentos e Lesões/mortalidade
8.
J Coll Physicians Surg Pak ; 29(8): 749-752, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31358097

RESUMO

OBJECTIVE: To evaluate the presentation, diagnosis, management and outcome of acute pulmonary embolism for assessing the factors impacting mortality in such patients. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan, from July 2015 to July 2018. METHODOLOGY: Patients presenting with clinical suspicion of pulmonary embolism were subjected to a diagnostic algorithm consisting of Wells Rule, D-Dimer testing, echocardiography and CT pulmonary angiogram. Patients diagnosed with pulmonary embolism were subdivided into massive and submassive pulmonary embolism groups. Most patients diagnosed with massive pulmonary embolism were treated with streptokinase injection. For those diagnosed as submassive pulmonary embolism, the standard therapy remained anticoagulation with intravenous heparin, both the subsets of patients were further put on oral warfarin. Clinical outcome was defined as combined end-point including death during hospital stay, recurrence of PE and meed for repeat thrombolysis. RESULTS: A total of 174 patients diagnosed with pulmonary embolism were studied. The mean age was 49.1 +14.8 years (range 23-88 years) with 109 (62.6%) patients being male. The in-hospital clinical course was uneventful in 144 (83%) patients. Twenty-two patients (12.6%) patients died, of whom 3 died from major bleeding, one from cancer, and 18 from the pulmonary embolism process (14 patients from refractory shock and 4 patients from recurrent PE). A total of 8 (4.6%) had fatal or non-fatal recurrent PE. In patients who had echocardiography both pre- and post-thrombolysis, initial RV dysfunction was reversible in 136 (78%) within 48h following thrombolytic therapy. By univariate analysis, only shock (SBP) and delay in diagnosis for more than 6 hours were associated with adverse event. CONCLUSION: Early diagnosis by doing urgent CTPA in patients with suspected acute PE is the cornerstone in reducing mortality in acute PE patients.


Assuntos
Anticoagulantes/uso terapêutico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/tratamento farmacológico , Estreptoquinase/uso terapêutico , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paquistão/epidemiologia , Embolia Pulmonar/mortalidade , Recidiva , Atenção Terciária à Saúde , Terapia Trombolítica
9.
BMJ ; 366: l4416, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358508

RESUMO

OBJECTIVES: To evaluate the association between experience in the management of acute pulmonary embolism, reflected by hospital case volume, and mortality. DESIGN: Multinational population based cohort study using data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry between 1 January 2001 and 31 August 2018. SETTING: 353 hospitals in 16 countries. PARTICIPANTS: 39 257 consecutive patients with confirmed diagnosis of acute symptomatic pulmonary embolism. MAIN OUTCOME MEASURE: Pulmonary embolism related mortality within 30 days after diagnosis of the condition. RESULTS: Patients with acute symptomatic pulmonary embolism admitted to high volume hospitals (>40 pulmonary embolisms per year) had a higher burden of comorbidities. A significant inverse association was seen between annual hospital volume and pulmonary embolism related mortality. Admission to hospitals in the highest quarter (that is, >40 pulmonary embolisms per year) was associated with a 44% reduction in the adjusted odds of pulmonary embolism related mortality at 30 days compared with admission to hospitals in the lowest quarter (<15 pulmonary embolisms per year; adjusted risk 1.3% v 2.3%; adjusted odds ratio 0.56 (95% confidence interval 0.33 to 0.95); P=0.03). Results were consistent in all sensitivity analyses. All cause mortality at 30 days was not significantly reduced between the two quarters (adjusted odds ratio 0.78 (0.50 to 1.22); P=0.28). Survivors showed little change in the odds of recurrent venous thromboembolism (odds ratio 0.76 (0.49 to 1.19)) or major bleeding (1.07 (0.77 to 1.47)) between the low and high volume hospitals. CONCLUSIONS: In patients with acute symptomatic pulmonary embolism, admission to high volume hospitals was associated with significant reductions in adjusted pulmonary embolism related mortality at 30 days. These findings could have implications for management strategies.


Assuntos
Hemorragia/epidemiologia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Embolia Pulmonar/mortalidade , Tromboembolia Venosa/epidemiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/terapia , Recidiva , Sistema de Registros , Resultado do Tratamento
10.
Turk Kardiyol Dern Ars ; 47(4): 273-280, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31219452

RESUMO

OBJECTIVE: Although hemodynamic instability has been identified as the most established mortality predictor in acute pulmonary embolism (PE), the debate is still open about the prognostic significance of saddle pulmonary embolism (SPE). This study determined the in-hospital mortality rate of SPE patients diagnosed via computed tomographic pulmonary angiography (CTPA) and compared these cases with non-SPE patients. METHODS: The presence of SPE observed on CTPA was used to classify 492 consecutive patients into SPE and non-SPE groups. Different features were compared between the 2 groups, and independent predictors of in-hospital mortality in acute PE were identified. RESULTS: A total of 70 patients (14.2%) had SPE. In univariate analysis, the SPE group was seen to have a higher in-hospital mortality rate, as well as a lower oxygen saturation level and systolic and diastolic blood pressure in comparison with the non-SPE group (all p values <0.005). Multivariate analysis revealed that SPE was an independent predictor of in-hospital mortality in acute PE patients (Odds ratio: 9.21, 95% confidence interval: 3.40-24.89; p value <0.001). CONCLUSION: The results of this study indicated that SPE had a statistically significant importance in predicting in-hospital mortality and adverse events in PE patients. These findings were not consistent with many prior studies.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Embolia Pulmonar/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem
11.
Int J Clin Oncol ; 24(10): 1273-1283, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31073813

RESUMO

BACKGROUND: This study aimed to examine the clinical significance and risk factors of thromboembolic events (TEEs) in patients with ovarian carcinoma. METHODS: Patients with ovarian carcinoma treated at our hospital between 2000 and 2017 were identified. The risk factors of TEEs, including venous TEEs and arterial TEEs, and the association between TEEs and prognosis were investigated. Patients with TEEs were classified into two groups: those with severe TEEs, defined as patients who required urgent treatment for deep vein thrombosis, massive pulmonary embolism, acute myocardial infarction, and symptomatic cerebral infarction, and those with mild TEEs. The risk factors of severe TEEs and the association between severe TEEs and prognosis were investigated. RESULTS: A total of 369 patients were enrolled. Among them, 53 patients (14.4%) were complicated with TEEs. Clear cell carcinoma (CCC) was a greater risk factor of TEEs than serous carcinoma (hazard ratio [HR] = 2.81, p = 0.03). In multivariate analysis for survival, TEEs were a prognostic factor of poor progression-free survival (PFS; HR = 2.90, p < 0.01) and overall survival (OS; HR = 2.89, p < 0.01). Among 53 patients with TEEs, 17 (32.1%) developed severe TEEs. CCC was strongly associated with severe TEEs (HR = 42.6, p = 0.02). Multivariate analysis for survival demonstrated that severe TEEs were a risk factor of worse PFS (HR = 4.34, p < 0.01) and OS (HR = 3.30, p = 0.03). CONCLUSION: TEEs induced poor prognosis and was associated with CCC. A standard treatment for CCC should be included in the strategy of TEEs.


Assuntos
Adenocarcinoma de Células Claras/mortalidade , Cistadenocarcinoma Seroso/mortalidade , Procedimentos Cirúrgicos de Citorredução/mortalidade , Neoplasias Ovarianas/mortalidade , Embolia Pulmonar/mortalidade , Trombose Venosa/mortalidade , Adenocarcinoma de Células Claras/patologia , Adenocarcinoma de Células Claras/cirurgia , Cistadenocarcinoma Seroso/patologia , Cistadenocarcinoma Seroso/cirurgia , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Prognóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/patologia , Fatores de Risco , Taxa de Sobrevida , Trombose Venosa/etiologia , Trombose Venosa/patologia
12.
Adv Respir Med ; 87(2): 69-76, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31038716

RESUMO

INTRODUCTION: Pulmonary embolism (PTE) is a common cardiovascular emergency. We aimed to predict mortality in the acute phase and to assess the development of pulmonary hypertension in the chronic period with the combined use of red cell distribution width (RDW) and echocardiography (ECHO) for the prognosis of PTE. MATERIAL AND METHODS: Cases diagnosed with acute PTE were prospectively monitored in our clinic. The initial data of 56 patients were evaluated. The subjects were separated into two groups basing on RDW; group 1 had RDW ≥ 15.2%, while group 2 had RDW < 15.2%. RESULTS: Ninety-eight patients were enrolled in the study. We established the sensitivity (73.3%) and the specificity (73.2%) of RDW to determine mortality in the cases with PTE. RDW ≥ 15.2% value was significant as an independent risk factor for predicting mortality (OR:7.9 95% CI, 1.5-40.9 p = 0.013) in acute PTE. The mean tricuspid annular plane systolic excursion (TAPSE) value was significantly different between the group-1 (RDW ≥ 15.2%, 2.20 cm (± 0.43)) and group-2 (RDW < 15.2%, 1.85 cm (± 0.53))(p = 0.007). The threshold value for tricuspid jet velocity was > 2.35m/s, the sensitivity and specificity were 76.9% and 61.9%, respectively for predicting mortality (AUC: 0.724, 95% CI: 0.591-0.858, p = 0.033). CONCLUSION: Our results indicate that high RDW levels are an independent predictor of mortality in acute PTE. Lower TAPSE levels show right heart failure in PTE patients; this may also be indicative of right ventricular systolic function. We believe that developing new scoring systems, including parameters such as RDW, TAPSE, and tricuspid jet velocities, may be effective in determining the prognosis of pulmonary embolism.


Assuntos
Índices de Eritrócitos/fisiologia , Ventrículos do Coração/fisiopatologia , Embolia Pulmonar/sangue , Embolia Pulmonar/mortalidade , Doença Aguda , Biomarcadores/sangue , Ecocardiografia , Feminino , Humanos , Masculino , Prognóstico , Embolia Pulmonar/patologia , Fatores de Risco
13.
Ann Thorac Surg ; 108(4): 1154-1161, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31075248

RESUMO

BACKGROUND: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is technically demanding. We tried to identify the predictors for short- and long-term outcomes after PEA for CTEPH with aggressive use of pulmonary vasodilators, including epoprostenol sodium. METHODS: From 2005 to 2013, 122 CTEPH patients, whose preoperative mean pulmonary artery pressure (mPAP) was 47 ± 10 mm Hg and pulmonary vascular resistance was 847 ± 373 dynes/s/cm5, underwent PEA with hypothermic circulatory arrest. Before PEA, all patients underwent pulmonary vasodilator therapy, including epoprostenol sodium of 2 to 6 ng/kg/min. We collected the perioperative and follow-up data retrospectively to identify the predictors for early and late outcomes after PEA. RESULTS: In-hospital mortality was 7.4% (n = 9). Predictors for in-hospital death were age older than 65 years and New York Heart Association Functional Classification IV. Among the 113 PEA survivors, the mPAP and pulmonary vascular resistance significantly decreased. After the median follow-up of 6.8 years, the overall survival rates were 91.8%, 89.2%, 89.2%, 89.2%, and 86.1%, and the cardiac events-free rates were 100%, 98.1%, 95.8%, 85.5%, and 49.0%, at 1, 3, 5, 7, and 10 years, respectively, in the Kaplan-Meier model. A multivariate Cox proportional hazard model identified postoperative mPAP exceeding 30 mm Hg as the only predictor for late cardiac events. CONCLUSIONS: Early and late outcomes of PEA for CTEPH with perioperative aggressive pulmonary vasodilator treatment seem satisfactory. However, residual pulmonary hypertension remains challenging to achieve further improvement of late outcomes.


Assuntos
Endarterectomia , Hipertensão Pulmonar/terapia , Embolia Pulmonar/cirurgia , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Doença Crônica , Epoprostenol/uso terapêutico , Feminino , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/mortalidade , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Resistência Vascular , Vasodilatadores/uso terapêutico , Adulto Jovem
14.
Rev Med Chil ; 147(2): 145-152, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31095161

RESUMO

BACKGROUND: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. AIM: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). MATERIAL AND METHODS: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. RESULTS: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 -5.6) in the pulmonary embolism group. CONCLUSIONS: High MPV is an independent risk factor for mortality following an episode of VTE.


Assuntos
Volume Plaquetário Médio , Tromboembolia Venosa/mortalidade , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Plaquetas , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Neoplasias/complicações , Fragmentos de Peptídeos/sangue , Prognóstico , Embolia Pulmonar/sangue , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sepse/complicações , Análise de Sobrevida , Troponina/sangue , Tromboembolia Venosa/sangue , Tromboembolia Venosa/complicações , Trombose Venosa/sangue , Trombose Venosa/mortalidade
15.
Diagn Interv Radiol ; 25(4): 298-303, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31120428

RESUMO

PURPOSE: Catheter-directed thrombolysis (CDT) is an emerging, minimally invasive treatment for patients with massive and submassive pulmonary embolism (PE). The value of follow-up pulmonary angiography for evaluating improvement after CDT is limited by a paucity of large studies assessing its utility and role for additional intervention. The purpose of our study was to assess the role of next-day pulmonary angiography for CDT in patients with acute massive and submassive PE undergoing continuous pulmonary arterial pressure monitoring, and secondarily, determine factors that are correlated with a need for further therapy. METHODS: Patients who underwent CDT from 2006 to 2016 for massive and submassive PE were reviewed. Patient demographics, comorbidities, preprocedural lab results, noninvasive hemodynamic studies, and technical variables were recorded. Among patients receiving next-day angiography, those requiring further therapy, defined as continued CDT beyond the standard 24 hours (with or without catheter repositioning or exchange) and/or mechanical or suction thrombectomy were contrasted with those not requiring additional therapy to assess for the role of angiography and patient factors that correlate with need for further therapy. RESULTS: Thirty-two patients underwent CDT for massive (n=14) and submassive (n=18) PE. Eighteen (56.3%) were male, 14 (43.7%) were Caucasian, 18 (56.3%) were African-American, with a mean age of 66.2 years (range, 26-87 years). Of the 27 (84.4%) patients that underwent next-day pulmonary angiography, 16 (59.3%) did not require additional therapy and 11 (40.7%) did require additional therapy. Additional therapy included extended CDT beyond 24 hours (n=4), mechanical/suction thrombectomy (n=5), or both extended CDT and mechanical/suction thrombectomy (n=2). Younger age (50.1 vs. 62.2 years, P = 0.039) was correlated with a need for further therapy. Initial (40.7 vs. 34.8 mmHg, P = 0.248), next-day (31.5 vs. 26.3 mmHg, P = 0.259), and interval change (4.6 vs. 8.0 mmHg, P = 0.669) in pulmonary artery pressures were not statistically significant between patient subsets. Preprocedural right ventricular/left ventricular ratio (RV/LV) also did not differ significantly (1.74 vs. 1.75, P = 0.961). Thirty-day mortality was comparable (2 vs. 1, P = 0.332). CONCLUSION: Next-day pulmonary angiography is a useful method to identify patients needing additional therapy including extended CDT and/or mechanical or suction thrombectomy in acute PE management. Pulmonary arterial pressures and preprocedural RV/LV ratios were not found to be predicative of those requiring further intervention.


Assuntos
Angiografia/métodos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/terapia , Terapia Trombolítica/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateteres , Meios de Contraste/administração & dosagem , Feminino , Seguimentos , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Artéria Pulmonar/fisiologia , Embolia Pulmonar/etnologia , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Trombectomia/métodos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X/métodos
16.
J Med Life ; 12(1): 15-20, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31123520

RESUMO

Whether syncope as a presenting symptom independently classifies acute pulmonary embolism (APE) into a high mortality risk group remains a matter of controversy. We retrospectively included all consecutive patients admitted to our clinic with APE from January 2014 to December 2016. Our sample consisted of 76 patients with a mean age of 69 ±13.6 years, 64.5% female. 14.3% presented with syncope at admission. In-hospital mortality was 20.8%. Patients with syncope were more likely to require inotropic support (OR = 5.2, 95 % 1.17-23.70, p=0.03) due to the association of cardiogenic shock (OR= 15.95% CI 3.02-74.32, p < 0.001) and systolic blood pressure below 90 mmHg (OR=5.52, 95% CI 1.24-24.47, p=0.03). Patients with syncope had a higher PESI score (150.9 ± 51.1 vs 99.9 ± 30.1, p < 0.001) and a greater in-hospital mortality (OR= 4.5, 95% CI 1.14-17.62, p=0.03). However, multivariate logistic regression equations did not identify syncope as an independent predictor of mortality. In our sample, syncope did not independently reclassify the patient in a higher mortality group, but due to the association with hemodynamic instability, which remains the primary tool in therapeutic decision-making.


Assuntos
Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Síncope/complicações , Doença Aguda , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Curva ROC , Estudos Retrospectivos
17.
Medicine (Baltimore) ; 98(22): e15931, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31145362

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) is one of the most successful orthopedic surgeries performed in recent decades. However, controversies still exist between conducting simultaneous or staged bilateral TKA. The objective of this study is to conduct a systematic review assessing the clinical outcome associated with simultaneous bilateral and staged bilateral total knee arthroplasty (BTKA). METHODS: A search was applied to CNKI, Embase, Medline, and Cochrane central database (January 2000-July 2018). All studies that compared simultaneous bilateral TKA (simBTKA) with staged bilateral TKA (staBTKA) without language restriction were reviewed, and qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis completed. RESULTS: The 18 studies were identified to be eligible. The 18 comparative studies published from 2001 to 2018, covered 73617 participants in the simBTKA group and 61838 in the staBTKA group, respectively. Results of meta-analyses indicated that simBTKA showed a lower risk of deep infection and respiratory complications, but increased mortality, pulmonary embolism (PE), and deep-vein thrombosis (DVT) compared with staBTKA. There were no significant differences in revision, superficial infection, arthrofibrosis, cardiac complications, neurological complications and urinary complications between procedures. CONCLUSIONS: Since there are risks and benefits to both procedures, these potential complications must be interpreted in light of each individual patient's needs and concerns. Further research must be conducted, in the form of a randomized clinical trial, to evaluate the outcomes mentioned in this review.


Assuntos
Artroplastia do Joelho/mortalidade , Artroplastia do Joelho/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Fatores de Risco , Resultado do Tratamento , Trombose Venosa/etiologia , Trombose Venosa/mortalidade
18.
Int J Surg ; 66: 48-52, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31026517

RESUMO

BACKGROUND: This study aimed to identify the risk factors and complications associated with mortality in elderly patients with femoral fracture after a fall from the ground level. METHODS: This retrospective study reviewed data pertaining to elderly patients aged ≥65 years who were admitted into a Level I trauma center, between January 1, 2009 and December 31, 2017. Multivariate logistic regression analysis was performed to identify independent effects of univariate predictive variables on the occurrence of mortality. RESULTS: Of 2407 enrolled elderly patients, there were 42 mortal and 2365 survival patients. A greater percentage of fatal patients than survival patients had a head injury with abbreviated injury scale (AIS) score ≥ 2 in the head/neck region (4.8% vs. 0.7%, respectively; p = 0.042). Multivariate logistic regression analysis revealed that the age (odds ration [OR] 1.1, 95% confident interval [CI] 1.0-1.1, p < 0.001), pre-existence of end-stage renal disease (ESRD) (OR 3.2, 95% CI 1.2-8.7, p = 0.023), and subarachnoid hemorrhage (SAH) (OR 12.1, 95% CI 1.3-113.9, p = 0.029) were significant independent risk factors for mortality in elderly patients with a femoral fracture resulting from a ground level fall. The patients in mortality group had a significantly higher rates of pneumonia (OR 28.6, 95% CI 14.6-55.9, p < 0.001), respiratory failure (OR 68.7, 95% CI 32.2-146.4, p < 0.001), sepsis (OR 26.3, 95% CI 10.9-63.4, p < 0.001), and pulmonary embolism (OR 14.4, 95% CI 1.6-131.6, p = 0.002) than those in the survival groups. CONCLUSIONS: This study identified age, pre-existence of ESRD, and SAH as significant independent risk factors for mortality in elderly patients with femoral fracture in a fall. However, ESRD and SAH only contribute to the mortality in a small group of patients. In contrast, respiratory complications contributed greatly to mortality. Thus aggressive chest-protective measures are encouraged to decrease the respiratory complications associated with femoral fracture in elderly patients.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Fraturas do Fêmur/complicações , Idoso , Idoso de 80 Anos ou mais , Traumatismos Craniocerebrais/mortalidade , Estudos Transversais , Feminino , Fraturas do Fêmur/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Masculino , Traumatismo Múltiplo/mortalidade , Pneumonia/complicações , Pneumonia/mortalidade , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Sistema de Registros , Insuficiência Respiratória/complicações , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/mortalidade , Taiwan/epidemiologia , Centros de Traumatologia
19.
Vasc Med ; 24(2): 103-109, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30834822

RESUMO

This study retrospectively compared the outcomes of patients who received ultrasound facilitated catheter-directed thrombolysis (UFCDT) versus systemically administered 'half-dose' thrombolysis (HDT) in 97 patients with PE. The outcomes assessed included changes in baseline pulmonary artery systolic pressure (PASP), right ventricle/left ventricle ratio (RV/LV), cost and duration of hospitalization, death, bleeding, and recurrent venous thromboembolism in the short and intermediate term follow-up. Analyses were performed using a covariance adjustment propensity score approach to address baseline differences between groups in variables associated with PASP and RV/LV, covarying baseline scores. The baseline mean ± SE PASP dropped from 49.3 ± 1.1 to 32.5 ± 0.3 mmHg at 36 hours in the HDT group, and from 50.6 ± 1.2 to 35.1 ± 0.4 mmHg in the UFCDT group; group × time interaction p-value = 0.007. Corresponding drops in the RV/LV were from a baseline of 1.26 ± 0.05 to 1.07 ± 0.01 in the HDT group and from 1.30 ± 0.05 to 1.14 ± 0.01 in the UFCDT group at 36 hours; group × time interaction p-value = 0.269. Statistically significant decreases were noted in PASP and RV/LV for both the HDT and UFCDT at 36 hours and follow-up. PASP through follow-up was significantly lower in the HDT than the UFCDT group. Likewise, RV/LV was lower in the HDT group. The duration and cost of hospitalization were lower in the HDT group (6.2 ± 1.4 days vs 1.9 ± 0.3 days, p < 0.001; US$12,000 ± $3000 vs $74,000 ± $6000, p < 0.001). We conclude that both UFCDT and HDT lead to rapid reduction of PASP and RV/LV, whereas HDT leads to a lower duration and cost of hospitalization.


Assuntos
Cateterismo , Fibrinolíticos/administração & dosagem , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ultrassonografia de Intervenção , Idoso , Cateterismo/efeitos adversos , Cateterismo/economia , Redução de Custos , Análise Custo-Benefício , Custos de Medicamentos , Feminino , Fibrinolíticos/efeitos adversos , Fibrinolíticos/economia , Hemodinâmica/efeitos dos fármacos , Custos Hospitalares , Humanos , Infusões Intravenosas , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Recidiva , Estudos Retrospectivos , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/economia , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Ativador de Plasminogênio Tecidual/economia , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/economia
20.
Vasc Med ; 24(3): 230-233, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30834824

RESUMO

Little is known about the temporal trends and outcomes for extra-corporeal membrane oxygenation (ECMO) in patients with high-risk pulmonary embolism (PE) in the United States. We queried the National Inpatient Sample (NIS) database from 2005 to 2013 to identify patients admitted with high-risk PE. Our objective was to determine trends for ECMO use in patients with high-risk PE. We also assessed in-hospital outcomes among patients with high-risk PE receiving ECMO. We evaluated 77,809 hospitalizations for high-risk PE. There was an upward trend in the utilization of ECMO from 0.07% in 2005 to 1.1% in 2013 ( p = 0.015). ECMO was utilized more in urban teaching hospitals and large hospitals. ECMO use was associated with lower mortality in patients with massive PE ( p < 0.001). In-hospital mortality for patients receiving ECMO was 61.6%, with no change over the observational period ( p = 0.68). Our investigation revealed several independent predictors of increased mortality in patients with high-risk PE using ECMO as hemodynamic support, including: age, female sex, obesity, congestive heart failure, and chronic pulmonary disease. ECMO, therefore, as a rescue strategy or bridge to definitive treatment, may be effective in the management of high-risk PE when selecting patients with favorable clinical characteristics.


Assuntos
Oxigenação por Membrana Extracorpórea/tendências , Embolia Pulmonar/terapia , Adulto , Tomada de Decisão Clínica , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
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