Nimrita Dhanjal’s research while affiliated with Winthrop University Hospital and other places

PURPOSE: To determine whether CTPA accurately portrays right ventricular (RV) and pulmonary artery (PA)dilatation and to correlate these findings with echocardiographic data in patients with central PE. METHODS: We retrospectively reviewed data of consecutive patients with central PE diagnosed by CTPA at our institution over a 3 year period. We recorded demographic parameters, clinical findings at presentation, CTPA and echocardiographic data. CTPA and echo measurements of RV size and RV/LV ratio were obtained. Main PA size was obtained from CTPA and evaluation for deep vein thrombosis (DVT) was determined from the venous phase of the CT (CTV). RESULTS: Thirty five patients (16=F) with central PE were identified. Mean age was 58 years (range 31-86).Only 3 patients had hypotension and all improved with iv fluids. EKG showed sinus tachycardia in 88%, S1Q3T3 pattern in 24%, and ST-T-wave changes in 32%. CTPA showed saddle emboli in 4 and bilateral main thrombi in 17 patients. Echocardiograms within 48 hours of CTPA were available in 18 patients. RV/LV ratios were 1.0 or greater on CTPA in 77% of patients and the RV/LV ratio correlated with echo data(r=0.68, p=0.006). PA enlargement (>30mm) by CT was present 67%. Mean PA size was 31 mm (range 25-39). Estimated RV pressure (RVSP) by echo, when available, averaged 44 mm Hg (range 20-69) but there was no correlation between PA size and RVSP. More patients with abnormal EKG's had RV/LV ratio > 1 on CTPA (9/14) than on echo (6/14). Abnormal findings on EKG were not associated with elevated RVSP or RV enlargement on echo. DVT was documented in 17 patients. CONCLUSION: CTPA /CTV provides useful information about RV dilatation and enlargement of the PA, as well as confirming the presence of DVT with a single study. RV enlargement and an RV/LV > 1 on CTPA correlate well with echocardiographic findings and are available without further studies. CLINICAL IMPLICATIONS: In patients with central PE,CTPA can reliably identify RV and PA enlargement and may obviate the need for echocardiogram. DISCLOSURE: Maritza Groth, No Financial Disclosure Information; No Product/Research Disclosure Information

PURPOSE: To review the presentation and management of patients with central pulmonary embolism (PE) at a University Medical Center. Central PE was defined as clot in the main pulmonary artery or multiple lobar branches. METHODS: We retrospectively reviewed the records of consecutive patients with central PE detected by CT pulmonary angiography (CTPA). We recorded demographic data, clinical findings at presentation, including heart rate, blood pressure, oxygen saturation, EKG findings, as well as echocardiographic and CTPA evidence of right ventricular dilatation. Treatment options, including thrombolysis, heparin, and inferior vena cava (IVC) filter were noted. RESULTS: Nineteen adult patients with central clot on CTPA were identified. Mean age was 60 years(range 33 to 86) and 10 were females. All patients had evidence of right ventricular (RV) dilatation on CTPA (defined as a ratio of RV/left ventricular (LV)>1.0).Only 4 patients were hypotensive on presentation: 2 corrected with fluids; one had a cardiac arrest shortly after presentation and died in <12 hours; the other was ventilated and on pressors and received tissue plasminogen activator (tPA)with improvement in hemodynamics. Heart rate at presentation was >100/minute in 13 patients (73%). Hypoxemia was present in 13 (73%). Electrogradiographic changes of RV strain were present in 6 patients (32%): three of these patients received tPA.Ten patients also had deep vein thrombosis (DVT)and 8 received IVC filters in addition to anticoagulation. One patient died of underlying extensive malignancy. There were no episodes of recurrent PE prior to discharge. CONCLUSION: Most patients with central clot were not hypotensive even with significant RV dilatation on CTPA, a finding associated with RV dysfunction. A similar rapid clinical resolution was seen in patients treated with either heparin or tPA and no patient required escalation of therapy due to clinical deterioration. CLINICAL IMPLICATIONS: CTPA is a useful tool to detect RV dilatation. The presence of large central pulmonary emboli and RV dilatation alone on CTPA does not indicate the need for thrombolysis, as most patients improved rapidly with routine anticoagulation. DISCLOSURE: Nimrita Dhanjal, None.

Synopsis: An examination of the effects of positive end-expiratory pressure on lung recruitment was studied using computed tomographic imaging. Source: Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354:1775-1786.