Value of right ventricular dysfunction for prognosis in pulmonary embolism☆

Abstract 

Background

Acute pulmonary embolism (APE) patients with right ventricular dysfunction (RVD) have a worse prognosis. We assessed RVD, deciding the indexes correlating best with prognosis.

Methods

The prospective multi-center study included 520 consecutive APE patients from 41 collaborating hospitals in China, between June 2002 and November 2004. RVD was diagnosed in the presence of at least 2 of the following: right ventricular (RV) dilatation, loss of inspiratory collapse of inferior vena cava (IVC), right ventricular hypokinesis, tricuspid regurgitant jet velocity >2.8 m/s.

Results

Mean age was 57.4±14.1 years and 323 patients (62.1%) were male. The 14-day mortality in normotensive patients with RVD was higher (2.0% vs 0.4%, p<0.01) than without RVD. RVD was associated with adverse 14-day outcomes (OR 5.23, 95% CI, 2.44–11.23) and the combination of RV dilation and IVC broadening was more valuable than the combination of RV dilation and RV hypokinesis (p<0.01). A multiple logistic regression model implied that RVD, right/left ventricular end-diastolic diameter ratio (RVED/LVED) and systolic pulmonary artery pressure (SPAP) be independent predictors of adverse 14-day clinical outcomes (p<0.01). ROC curve showed that the best cut-off values of RVED/LVED and SPAP were 0.67 and 60 mm Hg, respectively. Hemodynamic instability, 14-day clinical outcome, and SPAP were independent harbingers for 3-month outcomes (p<0.01).

Conclusions

RVD was a discriminator for a poor prognosis in normotensive patients. Early detection of RVD (especially combination of RV dilation and IVC broadening, RVED/LVED>0.67 and/or SPAP>60 mm Hg) was beneficial for identifying high-risk patients. Hemodynamic instability, 14-day clinical outcomes, and SPAP independently predicted 3-month clinical outcomes.

Abbreviations: APE, acute pulmonary embolism, PE, pulmonary embolism, RVD, right ventricular dysfunction, CTPA, computed tomographic pulmonary angiography, TTE, transthoracic echocardiography, RVED/LVED, right and left ventricular end-diastolic diameter ratio in the parasternal long-axis view, SPAP, systolic pulmonary artery pressure, IVC, inferior vena cava, PAA, pulmonary artery angiography.

Keywords: Pulmonary embolism, Right ventricular dysfunction, Transthoracic echocardiography, Prognosis