Automated volumetric analysis of four cardiac chambers in pulmonary embolism

Summary

Identification of patients with acute pulmonary embolism (PE) who might be at risk of circulatory collapse by using a fast, automated system is highly desired. It was our objective to investigate whether automated cardiac volumetric analysis following computerised tomographic pulmonary angiography (CTPA) is useful to identify increased clot load and adverse prognosis in patients with acute PE. We retrospectively analysed a consecutive series of non-gated CTPA studies of 124 patients with acute PE and 43 controls. Right and left ventricular diameters (RV/LV) were measured on four-chamber view, while each cardiac chamber underwent automatic volumetric measurements. Findings were correlated to the pulmonary arterial obstruction index (PAOI). Outcome was expressed by admission to an intensive care unit (ICU) or mortality within 30 days. There was a significant positive correlation between the PAOI and the volumes of the right side cavities (r=0.25 for the atrium and r=0.49 for the ventricle), and between the right-to-left atrial and ventricular volume ratios (r=0.49 and r=0.57, respectively). Results for the combined outcome of mortality or ICU admission that fell in the upper tertile of the right atrial and right ventricular volumes yielded hazard ratios of 3.9 and 3.3, respectively, compared to those in the lower tertile. RV/LV diameter ratio did not correlate with outcome. In conclusion, adverse outcome and significant pulmonary clot load in patients with acute PE are associated with a volume shift towards right heart cavities, which correlates to prognosis better than the CT-measured RV/LV diameter ratio, suggesting the advantage of using fast fully automatic volumetric analysis to identify patients at risk.

Keywords

Computerised tomography - pulmonary embolism - cardiac volumes

• References

• 1 Piazza G, Goldhaber SZ. Management of submassive pulmonary embolism. Circulation 2010; 122: 1124-1129.
• 2 Remy-Jardin M, Pistolesi M, Goodman LR. et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007; 245: 315-329.
• 3 Hariharan P, Takayesu JK, Kabrhel C. Association between the Pulmonary Embolism Severity Index (PESI) and short-term clinical deterioration. Thromb Haemost 2011; 105: 706-711.
• 4 Fraga M, Taffe P, Mean M. et al. The interrater reliability of the Pulmonary Embolism Severity Index. Thromb Haemost 2010; 104: 1258-1262.
• 5 Jaff MR, McMurtry MS, Archer SL. et al. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation 2011; 123: 1788-1830.
• 6 Lecumberri R, Soler S, Del Toro J. et al. Effect of the time of diagnosis on outcome in patients with acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2011; 105: 45-51.
• 7 Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002; 121: 877-905.
• 8 Pesavento R, de Conti G, Minotto I. et al. The value of 64-detector row computed tomography for the exclusion of pulmonary embolism. Thromb Haemost 2011; 105: 901-907.
• 9 Douma RA, Hofstee HM, Schaefer-Prokop C. et al. Comparison of 4- and 64-slice CT scanning in the diagnosis of pulmonary embolism. Thromb Haemost 2010; 103: 242-26.
• 10 Kucher N, Goldhaber SZ. Risk stratification of acute pulmonary embolism. Semin Thromb Hemost 2006; 32: 838-847.
• 11 Becattini C, Agnelli G, Vedovati MC. et al. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J 2011; 323: 1657-1663.
• 12 Qanadli SD, El Hajjam M, Vieillard-Baron A. et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. Ajr 2001; 176: 1415-1420.
• 13 Aviram G, Rogowski O, Gotler Y. et al. Real-time risk stratification of patients with acute pulmonary embolism by grading the reflux of contrast into the inferior vena cava on computerized tomographic pulmonary angiography. J Thromb Haemost 2008; 06: 1488-1493.
• 14 Abadi S, Roguin A, Engel A. et al. Feasibility of automatic assessment of four-chamber cardiac function with MDCT: Initial clinical application and validation. Eur J Radiol 2009; 74: 175-181.
• 15 Ecabert O, Peters J, Schramm H. et al. Automatic model-based segmentation of the heart in CT images. IEEE Trans Med Imaging 2008; 27: 1189-1201.
• 16 Lorenz C, von Berg J. A comprehensive shape model of the heart. Med Image Anal 2006; 10: 657-670.
• 17 van der Meer RW, Pattynama PM, van Strijen MJ. et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005; 235: 798-803.
• 18 Araoz PA, Gotway MB, Trowbridge RL. et al. Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism. J Thoracic Imag 2003; 18: 207-216.
• 19 Collomb D, Paramelle PJ, Calaque O. et al. Severity assessment of acute pulmonary embolism: evaluation using helical CT. Eur Radiol 2003; 13: 1508-1514.
• 20 Ghaye B, Ghuysen A, Willems V. et al. Severe pulmonary embolism:pulmonary artery clot load scores and cardiovascular parameters as predictors of mortality. Radiology 2006; 239: 884-891.
• 21 Schoepf UJ, Kucher N, Kipfmueller F. et al. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004; 110: 3276-3280.
• 22 Oliver TB, Reid JH, Murchison JT. Interventricular septal shift due to massive pulmonary embolism shown by CT pulmonary angiography: an old sign revisited. Thorax 1998; 53: 1092-1094. discussion 1088-1089.
• 23 Araoz PA, Gotway MB, Harrington JR. et al. Pulmonary embolism: prognostic CT findings. Radiology 2007; 242: 889-897.
• 24 Kang DK, Ramos-Duran L, Schoepf UJ. et al. Reproducibility of CT signs of right ventricular dysfunction in acute pulmonary embolism. Ajr 2010; 194: 1500-1506.
• 25 Stein PD, Matta F, Yaekoub AY. et al. Reconstructed 4-chamber views compared with axial imaging for assessment of right ventricular enlargement on CT pulmonary angiograms. J Thromb Thrombolysis 2009; 28: 342-347.
• 26 Henzler T, Krissak R, Reichert M. et al. Volumetric analysis of pulmonary CTA for the assessment of right ventricular dysfunction in patients with acute pulmonary embolism. Acad Radiol 2010; 17: 309-315.
• 27 Chung T, Emmett L, Khoury V. et al. Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly. J Am Soc Echocardiogr 2006; 19: 347-353.
• 28 Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Int Med 2002; 136: 691-700.
• 29 Aviram G, Steinvil A, Berliner S. et al. The association between the embolic load and atrial size in acute pulmonary embolism. J Thromb Haemost 2011; 09: 293-299.
• 30 Lu MT, Cai T, Ersoy H. et al. Comparison of ECG-gated versus non-gated CT ventricular measurements in thirty patients with acute pulmonary embolism. Int J Cardiovasc Imag 2009; 25: 101-107.