Overload of the Right Ventricle in Patients with Pulmonary Embolism: Analysis of New Evaluation Criteria

Abstract

INTRODUCTION: The increasing incidence of pulmonary embolism (PE) and high mortality from it necessitates development of new echocardiographic (EchoCG) criteria for assessing the severity of pressure and volume overload of the right ventricle (RV) in patients with PE.

AIM: To perform critical analysis of the developed EchoCG criteria of overload of the right heart chambers in PE with the aim to determine severity of the course and outcomes of the disease.

MATERIALS AND METHODS: The study included 428 patients with PE divided to 4 groups: group 1 — 42 patients with recorded death, group 2 — 51 patients with hemodynamically significant disease, group 3 — 193 hemodynamically stable patients with EchoCG signs of the overload of the right ventricle, group 4 — 142 patients with no identified symptoms. Comparison of the developed EchoCG criteria was conducted: the volume of tricuspid regurgitation, its ratio to the volume of the right atrium and the stroke volume of the heart, and also the pressure in the pulmonary trunk, the pressure gradient on the pulmonic valve and its ratio to the pressure gradient on the tricuspid valve in the studied groups with the determination of threshold values having diagnostic and prognostic significance.

RESULTS: It was found that the level of the estimated pressure gradient on the pulmonic valve has statistically significant correlation with the hemodynamic significance of the course of the disease (r = 0.91, р < 0.01) and fatal outcome (r = 0.99, р < 0.01) and possesses high sensitivity (more than 92.7%) and specificity (more than 97.8%). This parameter is proved to be the most important prognostic EchCG criterion. To determine the expression of the RV dysfunction and the priority flow of blood from its cavity, the following parameters equivalent to EhcoCG, such as the ratio of pressure gradient on the pulmonic artery to the pressure gradient on the tricuspid valve and the ratio of the tricuspid regurgitation volume to the stroke volume, are also significant.

CONCLUSION: Calculation of the pressure gradient on the pulmonic valve and its correlation with the pressure gradient on the tricuspid valve, just as the ratio of the volume of tricuspid regurgitation to the stroke volume can be reliable criteria for assessment of the hemodynamic significance of PE and predictors of its outcome.

Keywords

pulmonary embolism / overload of the right ventricle / echocardiography / diagnostic and prognostic criteria

References

[1] Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543–603. doi: 10.1093/eurheartj/ehz405

[2] Konstantinides S.V., Meyer G., Becattini C., et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) // Eur. Heart J. 2020. Vol. 41, No. 4. P. 543–603. doi: 10.1093/eurheartj/ehz405

[3] Bagrova IV, Kukharchik GA, Serebriakova VI, et al. The modern approaches to diagnostics of pulmonary embolism. Flebologiya. 2012;6(4):35–42. (In Russ).

[4] Багрова И.В., Кухарчик Г.А., Серебрякова В.И., и др. Современные подходы к диагностике тромбоэмболии легочной артерии // Флебология. 2012. Т. 6, № 4. С. 35–42.

[5] Berns SA, Schmidt EA, Neeshpapa AG, et al. Risk factors associated with the development of death events during the first year of follow-up after pulmonary thromboembolism. Medical Council. 2019;(5):80–5. (In Russ). doi: 10.21518/2079-701X-2019-5-80-85

[6] Бернес С.А., Шмидт Е.А., Неешпапа А.Г., и др. Факторы риска развития смертельных исходов в течение года наблюдения после тромбоэмболии легочной артерии // Медицинский совет. 2019. № 5. С. 80–85. doi: 10.21518/2079-701X-2019-5-80-85

[7] Kovaleva GV, Koroleva LYu, Amineva NV, et al. The difficulties in differential diagnosis of pulmonary thromboembolism in a therapeutic clinic. The rupture of the diverticulum of esophagus, imitating thromboembolism of the pulmonary artery (case from practice). Meditsinskiy Al’manakh. 2018;(1):98–100. (In Russ).

[8] Ковалёва Г.В., Королёва Л.Ю., Аминева Н.В., и др. Трудности дифференциальной диагностики тромбоэмболии легочной артерии в терапевтической клинике. Разрыв дивертикула пищевода, имитирующий тромбоэмболию легочной артерии (случай из практики) // Медицинский Альманах. 2018. № 1 (52). С. 98–100.

[9] Becattini C, Agnelli G. Acute treatment of venous thromboembolism. Blood. 2020;135(5):305–16. doi: 10.1182/blood.2019001881

[10] Becattini C., Agnelli G. Acute treatment of venous thromboembolism // Blood. 2020. Vol. 135, No. 5. Р. 305–316. doi: 10.1182/blood.2019001881

[11] Panchenko EP, Balahonova TV, Danilov NM, et al. Diagnosis and management of pulmonary embolism: Eurasian Association of Cardiology (EAC) Clinical Practice Guidelines (2021). Eurasian Heart Journal. 2021;(1):44–77. (In Russ). doi: 10.38109/2225-1685-2021-1-44-77

[12] Панченко Е.П., Балахонова Т.В., Данилов Н.М., и др. Диагностика и лечение тромбоэмболии легочной артерии: клинические рекомендации Евразийской ассоциации кардиологов для практических врачей (2021) // Евразийский кардиологический журнал. 2021. № 1. С. 44–77. doi: 10.38109/2225-1685-2021-1-44-77

[13] Barco S, Mahmudpur SH, Plunketka B, et al. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J. 2019;40(11):902–10. doi: 10.1093/eurheartj/ehy873

[14] Barco S., Mahmudpur S.H., Plunketka B., et al. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis // Eur. Heart J. 2019. Vol. 40, No. 11. Р. 902–910. doi: 10.1093/eurheartj/ehy873

[15] Burgos LM, Scatularo CE, Cigalini IM, et al. The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score. Eur Heart J Acute Cardiovasc Care. 2021;10(3):250–7. doi: 10.1093/ehjacc/zuaa007

[16] Burgos L.M., Scatularo C.E., Cigalini I.M., et al. The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score // Eur. Heart J. Acute Cardiovasc. Care. 2021. Vol. 10, No. 3. Р. 250–257. doi: 10.1093/ehjacc/zuaa007

[17] Lahham S, Fox JC, Thompson M, et al. Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study). J Ultrasound Med. 2019;38(3):695–702. doi: 10.1002/jum.14753

[18] Lahham S., Fox J.C., Thompson M., et al. Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study) // J. Ultrasound Med. 2019. Vol. 38, № 3. Р. 695–702. doi: 10.1002/jum.14753

[19] Russian Clinical Guidelines for the Diagnostics and Treatment of Chronic Venous Diseases. Flebologiya. 2018;12(3):146–240. (In Russ). doi: 10.17116/flebo20187031146

[20] Российские клинические рекомендации по диагностике и лечению хронических заболеваний вен // Флебология. 2018. Т. 12, № 3. С. 146–240. doi: 10.17116/flebo20187031146

[21] Netylko JE, Teterina MA, Pisaryuk AS, et al. Prognostic value of echocardiographic parameters in patients with pulmonary embolism. Klinicheskaya Farmakologiya i Terapiya. 2021;30(3):52–6. (In Russ). doi: 10.32756/0869-5490-2021-3-52-56

[22] Нетылько Ю.Э, Тетерина М.А., Писарюк А.С., и др. Прогностическое значение эхокардиографических параметров у пациентов с тромбо-эмболией легочной артерии // Клиническая фармакология и терапия. 2021. Т. 30, № 3. С. 52–56. doi: 10.32756/0869-5490-2021-3-52-56

[23] Neklyudova GV, Naumenko ZhK. Ultrasound diagnostic opportunities in pulmonology. Russian Pulmonology. 2017;27(2):283–90. (In Russ). doi: 10.18093/0869-0189-2017-27-2-283-290

[24] Неклюдова Г.В., Науменко Ж.К. Диагностические возможности ультразвуковых методов исследования в пульмонологической практике // Пульмонология. 2017. Т. 27, № 2. С. 283–290. doi: 10.18093/0869-0189-2017-27-2-283-290

[25] Dzhioeva ON, Orlov DO, Nikitin IG. Echocardiography in acute cardiovascular care. Part 2. Cardiac and lung ultrasound examination. Complex Issues of Cardiovascular Diseases. 2020;9(3):49–58. (In Russ). doi: 10.17802/2306-1278-2020-9-3-49-58

[26] Джиоева О.Н., Орлов Д.О., Никитин И.Г. Эхокардиография в неотложной кардиологии. Часть 2. Ультразвуковое исследование сердца и легких // Комплексные проблемы сердечно-сосудистых заболеваний. 2020. Т. 9, № 3. С. 49–58. doi: 10.17802/2306-1278-2020-9-3-49-58

[27] Lyhne MD, Kabrhel C, Giordano N, et al. The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism. Eur Heart J Cardiovasc Imaging. 2021;22(3):285–94. doi: 10.1093/ehjci/jeaa243

[28] Lyhne M.D., Kabrhel C., Giordano N., et al. The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism // Eur. Heart J. Cardiovasc. Imaging. 2021. Vol. 22, No. 3. Р. 285–294. doi: 10.1093/ehjci/jeaa243

[29] Kochmareva ЕА, Kokorin VА, Volkova АL, et al. Modern possibilities of prediction of clinical course and outcome of pulmonary embolism. Medical News of North Caucasus. 2017;12(4):476–83. (In Russ). doi: 10.14300/mnnc.2017.12133

[30] Кочмарева Е.А., Кокорин В.А., Волкова А.Л., и др. Современные возможности прогнозирования клинического течения и исхода тромбоэмболии легочной артерии // Медицинский вестник Северного Кавказа. 2017. Т. 12, № 4. С. 476–483. doi: 10.14300/mnnc.2017.12133

[31] Bautin AE, Osovskikh VV. Acute right ventricular failure. Messenger of Anesthesiology and Resuscitation. 2018;15(5):74–86. (In Russ). doi: 10.21292/2078-5658-2018-15-5-74-86

[32] Баутин А.Е., Осовских В.В. Острая правожелудочковая недостаточность // Вестник анестезиологии и реаниматологии. 2018. Т. 15, № 5. С. 74–86. doi: 10.21292/2078-5658-2018-15-5-74-86

[33] Erlikh AD, Barbarash OL, Berns SA, et al. SIRENA score for in-hospital mortality risk assessment in patients with acute pulmonary embolism. Russian Journal of Cardiology. 2020;25(4S):4231. (In Russ). doi: 10.15829/1560-4071-2020-4231

[34] Эрлих А.Д., Барбараш О.Л., Бернс С.А., и др. Шкала SIRENA для оценки риска госпитальной смерти у пациентов с острой лёгочной эмболией // Российский кардиологический журнал. 2020. Т. 25, № 4S. С. 4231. doi: 10.15829/1560-4071-2020-4231

[35] Arshad N, Bjøri E, Hindberg K, et al. Recurrence and mortality after first venous thromboembolism in a large population-based cohort. J Thromb Haemost. 2017;15(2):295–303. doi: 10.1111/jth.13587

[36] Arshad N., Bjøri E., Hindberg K., et al. Recurrence and mortality after first venous thromboembolism in a large population-based cohort // J. Thromb. Haemost. 2017. Vol. 15, No. 2. Р. 295–303. doi: 10.1111/jth.13587

[37] Sheypak AA. Gidravlika i gidropnevmoprivod. Osnovy mekhaniki zhidkosti i gaza. 6th ed. Moscow: INFRA-M; 2017. (In Russ).

[38] Шейпак А.А. Гидравлика и гидропневмопривод. Основы механики жидкости и газа. 6-е изд. М.: ИНФРА-М; 2017.

[39] Evlakhov VI, Pugovkin AP, Rudakova TL, et al. Vvedeniye v fiziologiyu serdtsa. Saint-Petersburg: SpetsLit; 2019. (In Russ).

[40] Евлахов В.И., Пуговкин А.П., Рудакова Т.Л., и др. Введение в физиологию сердца. СПб.: СпецЛит; 2019.

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