Predictors of residual pulmonary vascular obstruction after pulmonary embolism: Results from a prospective cohort study

Picart, Gael; Robin, Philippe; Tromeur, Cécile; Orione, Charles; Raj, Leela; Ferrière, Nicolas; Mao, Raphaël Le; Roux, Pierre‐Yves Le; Floch, Pierre-Yves Le; Lemarié, Catherine A.; Nonent, Michel; Leroyer, Christophe; Guégan, Marie; Lacut, Karine; Salaün, Pierre-Yves; Couturaud, Francis

doi:10.1016/j.thromres.2020.06.004

Cited by 16 publications

(14 citation statements)

References 36 publications

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“…This association was maintained at 6 months, with a discriminant threshold of 14%, which is consistent with the observation of Pesavento et al, although they used an outcome combining recurrent PE and CTEPH 23 . Other studies showed that PVO at PE diagnosis was predictive of recurrent PE, with PVO cutoff of 40% and 20% in patients with a first unprovoked PE and unselected PE, respectively 14,24 . Predictive values of recurrent PE have been also established for residual PVO at 6 months 25 .…”

Section: Discussionsupporting

confidence: 82%

“…23 Other studies showed that PVO at PE diagnosis was predictive of recurrent PE, with PVO cutoff of 40% and 20% in patients with a first unprovoked PE and unselected PE, respectively. 14,24 Predictive values of recurrent PE have been also established for residual PVO at 6 months. 25 Indeed, recurrent PE is a recognized risk factor for CTEPH, with the hypothesis that undiagnosed recurrent PE might contribute to persistent PVO.…”

Section: Discussionmentioning

confidence: 99%

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Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies

Fauché

Presles

Sanchez

et al. 2022

Journal of Thrombosis and Haemostasis

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Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a life‐threatening complication of a pulmonary embolism (PE) whose incidence and predictors are not precisely determined. Objective To determine the frequency and predictors for CTEPH after a first unprovoked PE. Patients/Methods In a randomized trial comparing an additional 18‐month warfarin versus placebo in patients after a first unprovoked PE initially treated with vitamin K antagonist for 6 months, we applied recommended CTEPH screening strategies through an 8‐year follow‐up to determine cumulative incidence of CTEPH. CTEPH predictors were estimated using Cox models. Pulmonary vascular obstruction (PVO) and systolic pulmonary arterial pressure (sPAP) at PE diagnosis and 6 months were studied by receiver operating curves analysis. All CTEPH cases and whether they were incident or prevalent were adjudicated. Results During a median follow‐up of 8.7 years, nine CTEPH cases were diagnosed among 371 patients, with a cumulative incidence of 2.8% (95% confidence interval [CI] 0.95–4.64), and of 1.31% (95% CI 0.01–2.60) after exclusion of five cases adjudicated as prevalent. At PE diagnosis, PVO > 45% and sPAP > 56 mmHg were associated with CTEPH with a hazard ratio (HR) of 33.00 (95% CI 1.64–667.00, p = .02) and 12.50 (95% CI 2.10–74.80, p < .01), respectively. Age > 65 years, lupus anticoagulant antibodies and non‐O blood groups were also predictive of CTEPH. PVO > 14% and sPAP > 34 mmHg at 6 months were associated with CTEPH (HR 63.90 [95% CI 3.11–1310.00, p < .01]and HR 17.2 [95% CI 2.75–108, p < .01]). Conclusion After a first unprovoked PE, CTEPH cumulative incidence was 2.8% during an 8‐year follow‐up. PVO and sPAP at PE diagnosis and at 6 months were the main predictors for CTEPH diagnosis.

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Section: Discussionsupporting

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies

Fauché

Presles

Sanchez

et al. 2022

Journal of Thrombosis and Haemostasis

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“…The incidence of RPVO following an index PE is in keeping with previously reported rates ranging from 19-51.8%. 10,11,14 There is a paucity of data regarding the long-term effects of reperfusion therapies on PE, and the few studies that investigated its impact came to different conclusions. Two small, prospective randomized trials reported that thrombolysis, compared with anticoagulation, might improve functional capacity and the persistence of pulmonary hypertension at long-term follow-up.…”

Section: Discussionmentioning

confidence: 99%

“…9 In addition, several studies found that RPVO is an independent predictor of recurrent venous thromboembolism (VTE). 10,11 Reperfusion therapies have been shown to improve short-term outcomes by rapidly and effectively reversing the hemodynamic burden that PE imposes on the pulmonary circulation and the right heart. 12 Theoretically, the rapid and effective clot resolution exerted by reperfusion therapies could possibly minimize the development of long-term consequences of PE, including RV dysfunction and CTEPH.…”

Section: Introductionmentioning

confidence: 99%

Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism: a retrospective observational study

Lio

Bashir

Lakhter

et al. 2023

Preprint

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Background: Major progress in reperfusion strategies has substantially improved the short-term outcomes of patients with pulmonary embolism (PE), however, up to 50% of patients report persistent dyspnea after acute PE. This study aims to evaluate the impact of reperfusion therapies on clot resolution and compare the long-term outcomes following acute PE in patients treated with reperfusion therapies to anticoagulation alone. Methods: A retrospective study of the pulmonary embolism response team (PERT) registry at our institution between January 2017 and June 2021 and included patients with repeat imaging at 3 to 12 months. The primary outcome was to determine the incidence of residual pulmonary vascular obstruction (RPVO) following acute PE and clot burden was assessed for each patient. Secondary outcomes included the development of PE recurrence, right ventricular (RV) dysfunction, chronic thromboembolic pulmonary hypertension (CTEPH), readmission, and mortality at 12 months. Results: A total of 382 patients were included and 107 patients received reperfusion therapies followed by anticoagulation. Patients who received reperfusion therapies including systemic thrombolysis, catheter-directed thrombolysis and mechanical thrombectomy presented with a higher vascular obstructive index (VOI, 47% vs 28%, p<0.001), more frequent concomitant deep vein thrombosis (DVT, 69% vs 40%, p<0.001), and right heart strain on both computed tomographic pulmonary arteriography (CTPA, 82% vs 37%, p<0.001) and echocardiogram (81% vs 43%, p<0.001) at the time of diagnosis. A higher absolute reduction in VOI (45% vs 26%, p<0.001, 95% CI 14.0-25.6), greater improvement in RV function (82% vs 65%, p=0.021), lower 12-month mortality rate (2% vs 7%, p=0.038) and readmission rate (33% vs 46%, p=0.031) were observed in the reperfusion group. No statistically significant differences were found between groups in the development of CTEPH (8% vs 5%, p=0.488) and PE recurrence (8% vs 6%, p=0.646). Conclusion: We observed a more favorable survival, greater improvement in clot resolution and RV function in patients treated with reperfusion therapies. Future randomized control trials are needed to confirm our findings.

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“…In patients with PE or CTEPH, there is a growing interest in quantifying the pulmonary vascular obstruction index (PVOI), i.e., the percentage of the whole lung volume with perfusion defects. Indeed, a high pulmonary vascular obstruction index (PVOI) measured at the time of PE diagnosis was associated with an increased risk of residual obstruction ( 4 , 5 ) and recurrent venous thromboembolism (VTE) ( 6 , 7 ). Similarly, studies suggest that residual PVOI, when measured with lung scan after a minimum of 3 months of anticoagulant therapy, might be associated with a 2- to 3-fold increased risk of recurrent VTE ( 4 , 8 , 9 ).…”

Section: Introductionmentioning

confidence: 99%

Quantification of the pulmonary vascular obstruction index on ventilation/perfusion lung scintigraphy: Comparison of a segmental visual scoring to the Meyer score

Pennec

Tromeur²,

Orione³

et al. 2022

Front. Med.

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IntroductionQuantifying the pulmonary vascular obstruction index (PVOI) is essential for the management of patients with pulmonary embolism or chronic thromboembolic pulmonary hypertension (CTEPH). The reference method for quantifying the PVOI with planar lung ventilation/perfusion (V/Q) scintigraphy is the Meyer score, which was validated using pulmonary angiography as a reference standard. However, it is complex to use in daily practice. In contrast, a rapid and fast quantification method consists in estimating the PVOI based on the number of segmental perfusion defects. However, the accuracy of this method has never been evaluated. In this study, we aimed to compare PVOI quantification on planar V/Q scintigraphy assessed by a segmental visual scoring (SVS) to the Meyer score.Materials and methodsThe eligible study population consisted of consecutive patients who underwent planar V/Q scan for CTEPH screening. A central review was performed by three nuclear medicine physicians. PVOI was assessed by summing the number of segmental perfusion defects or equivalent (2 sub-segments = 1 segment = 5%) and by Meyer’s method. The two interpretations were performed 6 months apart. A Spearman rank correlation coefficient was calculated to evaluate correlation between the two measurement methods. An intra-class correlation (ICC) was calculated to assess agreement. A Bland et Altman plot analysis was used to evaluate agreement between the two measurements.ResultsA total of 226 V/Q scans were interpreted. Spearman rank correlation coefficient between SVS and Meyer was 0.963 (95%CI 0.952–0.971) for mismatched perfusion defects and 0.963 (95%CI 0.953–0.972) for perfusion defects regardless of ventilation. Intra-class correlation (ICC) for agreement was 0.978 (95%CI 0.972–0.983) for mismatched perfusion defects and 0.968 (95%CI 0.959–0.976) for perfusion defects regardless of ventilation. In Bland & Altmann analysis, the mean difference between the SVS method and the Meyer score was 0.42 and 0.61 for the mismatched or matched evaluation, respectively.ConclusionOur study shows a high correlation, and low differences in PVOI quantification when using a segmental visual scoring (SVS) as compared to the Meyer score. The SVS has the great advantage to be easy and rapid to apply in daily practice.

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Predictors of residual pulmonary vascular obstruction after pulmonary embolism: Results from a prospective cohort study

Cited by 16 publications

References 36 publications

Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies

Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies

Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism: a retrospective observational study

Quantification of the pulmonary vascular obstruction index on ventilation/perfusion lung scintigraphy: Comparison of a segmental visual scoring to the Meyer score

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