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. 2021 May 24;7(2):00414-2020.
doi: 10.1183/23120541.00414-2020. eCollection 2021 Apr.

Prognostic value of right atrial dilation in patients with pulmonary embolism

Markus H Lerchbaumer  1 , Matthias Ebner  2   3 , Christian O Ritter  4   5 , Laura Steimke  6 , Nina I J Rogge  6 , Carmen Sentler  6 , Aaron Thielmann  6 , Lukas Hobohm  7   8 , Karsten Keller  7   8 , Joachim Lotz  4   5 , Gerd Hasenfuß  5   6 , Rolf Wachter  5   6   9 , Bernd Hamm  1 , Stavros V Konstantinides  7   10 , Galit Aviram  11 , Mareike Lankeit  3   6   7   12
Affiliations

Prognostic value of right atrial dilation in patients with pulmonary embolism

Markus H Lerchbaumer et al. ERJ Open Res. .

Abstract

Aims: Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE).

Methods: Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.

Results: Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6).

Conclusions: RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.

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Conflict of interest statement

Conflict of interest: M.H. Lerchbaumer reports having received consultancy honoraria from Siemens Healthineers. Conflict of interest: M. Ebner has nothing to disclose. Conflict of interest: C.O. Ritter has nothing to disclose. Conflict of interest: L. Steimke has nothing to disclose. Conflict of interest: N.I.J. Rogge has nothing to disclose. Conflict of interest: C. Sentler has nothing to disclose. Conflict of interest: A. Thielmann has nothing to disclose. Conflict of interest: L. Hobohm reports personal fees from MSD and Actelion outside the submitted work. Conflict of interest: K. Keller has nothing to disclose. Conflict of interest: J. Lotz has nothing to disclose. Conflict of interest: G. Hasenfuß reports personal fees from Corvia, Servier, Impulse Dynamics, Novartis, AstraZeneca, Vifor Pharma, Berlin Chemie and Springer outside the submitted work. Conflict of interest: R. Wachter reports grants from Boehringer Ingelheim during the conduct of the study; personal fees and other support from Bayer, Berlin Chemie and Boehringer Ingelheim, other support from Boston Scientific, personal fees from Bristol-Myers-Squibb, personal fees and other support from CVRx, other support from Gilead and Johnson & Johnson, personal fees and other support from Medtronic and Novartis, personal fees from Pfizer, other support from Relypsa, personal fees from Sanofi, and personal fees and other support from Servier, outside the submitted work. Conflict of interest: B. Hamm reports personal fees from Canon Medical Imaging outside the submitted work. Conflict of interest: S.V. Konstantinides reports grants from the German Federal Ministry of Education and Research (BMBF 01EO1003 and BMBF 01EO1503) during the conduct of the study; grants and personal fees from Bayer, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Daiichi-Sankyo, personal fees from MSD, grants and personal fees from Pfizer–Bristol-Myers-Squibb, and grants and personal fees from Actelion, outside the submitted work. Conflict of interest: G. Aviram reports grants from Philips Medical Systems outside the submitted work. Conflict of interest: M. Lankeit reports grants from the German Federal Ministry of Education and Research (BMBF 01EO1003 and 01EO1503), and BRAHMS–Thermo Fisher Scientific, during the conduct of the study; and personal fees and nonfinancial support from Actelion, Bayer, Daiichi-Sankyo, MSD and Pfizer–Bristol-Myers-Squibb, and grants and personal fees from BRAHMS–Thermo Fisher Scientific, outside the submitted work.

Figures

FIGURE 1
FIGURE 1
Representative case of volumetric analysis using computed tomography pulmonary angiography. A 35-year-old male patient without relevant comorbidities presenting with dyspnoea, haemoptysis and chest pain (heart rate 92 beats·min−1, blood pressure 155/70 mmHg, respiratory rate 12 breaths·min−1, oxygen saturation 99%) and normal biomarker plasma concentrations (mid-regional pro-atrial natriuretic peptide 84 pmol·L−1, N-terminal pro-B-type natriuretic peptide 35 pg·mL−1 and high-sensitivity troponin T <5 pg·mL−1). The patient was treated with low molecular weight heparin followed by rivaroxaban and discharged after 4 days without suffering any relevant complications. a) Central thrombus in the right (and left) pulmonary artery and thrombus in left segmental pulmonary artery (marked with arrows). b, c) Automated reconstructed b) four-chamber and c) axial view with coloured overlay: right atrium (RA) 92 mL (yellow), left atrium (LA) 75 mL (purple), RA/LA volume ratio 1.23, right ventricle (RV) 233 mL (orange), left ventricle (LV) 203 mL (pink), myocardium (light blue). d, e) Automated d) sagittal and e) coronal multiplanar reconstruction. f) 3D volumetric model of the four cardiac chambers.
FIGURE 2
FIGURE 2
Prognostic performance of a) radiological and b) laboratory parameters, with regard to an in-hospital adverse outcome in pulmonary embolism patients. Area under the curve assessed by receiver operating characteristic analysis of a) right to left atrial (RA/LA) volume ratio on computed tomography pulmonary angiography, and b) mid-regional pro-atrial natriuretic peptide (MR-proANP), high-sensitivity troponin T (hsTNT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP).
See this image and copyright information in PMC

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