Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism

Abstract

The exact prevalence of mobile right heart thromboemboli (RHTh) in patients with pulmonary embolism (PE) is unknown, depending upon PE severity and the use of early echocardiography. Similarly, the mortality rate is variable, though RHTh detection appears to substantially increase the risk of death in patients with PE. The aim of this study was to assess the prevalence of RHTh in different risk categories in a wide series of patients with PE, and to analyse the effect of RHTh on in-hospital mortality. Among 1,716 patients enrolled in the Italian Pulmonary Embolism Registry, 1,275 (13.3% at high risk, 59.3% at intermediate risk and 27.4% at low risk) had echocardiography within 48 hours from hospital admission and entered the study. Overall, RHTh were detected in 57 patients (4.5%, at admission echocardiography in 88%): in 27/169 (16%) high-risk, in 29/756 (3.8%) intermediate-risk and 1/350 (0.3%) low-risk patients, respectively. At multivariate analysis, only advanced age (odds ratio [OR] 1.61, 95% confidence [CI] 1.27-2.03, p<0.0001), high-risk category (OR vs low-risk category 37.82, 95% CI 11.26-127.06, p<0.0001) and recurrent PE (OR 45.92, 95%CI 15.19-139.96, p<0.0001) showed a statistically significant effect on mortality. The presence of RHTh significantly increased the risk of dying (OR 3.89, 95%CI 1.98-7.67, p=0.0001) at univariate analysis, but this result was not mantained in the multivariate model (OR 1.64, 95%CI 0.75-3.60, p=0.216). In conclusion, though patients with RHTh had a more severe presentation of PE, this study did not detect an association between RHTh and prognosis.

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“…Similarly to our study, predictors of early mortality included indicators of hemodynamic instability and clinical parameters (sPESI score, SI, hypotension), while morphology of the thrombus did not affect prognosis. Similar results were obtained in subgroup analyses in the IPER [4] and ICOPER [1] registries.…”

“…Right heart thrombi are present in about 4% of patients with acute PE [1,3,4,6,11] but this rate increases to about 18% [2] to 22% [12] in patients hospitalized in intensive care units. In our centre, the rate of RiHT in patients with acute PE was about 2% (13 of 746 subsequent patients).…”

“…The authors of the guidelines on the diagnosis and treatment of acute PE noted that the presence of RiHT is associated with worse treatment outcomes [3]. According to other reports, treatment outcomes in patients with RiHT are comparable to those in the general population of acute PE patients [4][5][6]. Due to lack of randomized studies, it is difficult to establish the effect of RiHT on prognosis.…”

“…As stated in the European guidelines on the diagnosis and management of acute PE, the presence of RiHT is associated with worse outcomes [3]. In the recently reported Italian IPER registry that included 57 patients with RiHT, the latter was not found to be associate with early in-hospital mortality [4]. Some other studies also did not report an increased mortality in patients with acute PE and RiHT [5,6].…”

Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry

“…Although RiHT confirm pulmonary embolism, optimal therapy has not been defined and treatment selection is still a subject of debate. Most data are based on short case-series, their meta-analyses [2] or results of registries primarily focused on different aspects of pulmonary embolism [1,3]. Good outcome of RiHT patients has been reported in some series [4][5][6], but in other reports mortality exceeded 20%, even despite urgent thrombolysis [1,7,8].…”