Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate.
OBJECTIVE
The indications for the use of thrombolytic agents in massive pulmonary embolism (MPE) remain controversial and it has been suggested that transthoracic echocardiographic (TTE) examination, which is able to detect an associated right ventricular dysfunction, may cast light on this question. The goal of this study was to examine the incidence of acute cor pulmonale (ACP) in MPE, diagnosed on the basis of TTE criteria, its clinical implications and its resolution rate.


METHODS
Ten-year retrospective clinical study.


METHODS
A medical and a coronary intensive care unit, university hospital.


METHODS
One hundred sixty-one patients with proven MPE.


METHODS
Acute cor pulmonale was defined as right ventricular end-diastolic area / left ventricular end-diastolic area (RVEDA/LVEDA) ratio in the long axis greater than 0.6 associated with septal dyskinesia in the short axis. ACP patients were divided into three groups according to circulatory status: 32 patients without circulatory failure constituted group 1, 32 patients with circulatory failure requiring inotropic support, but free of metabolic acidosis, constituted group 2 and 34 patients in whom circulatory failure was associated with metabolic acidosis (defined by a base deficit >5 mEq/l) constituted group 3.


RESULTS
Acute cor pulmonale was present in 61% of patients with MPE and carried a 23% mortality, but this mortality was very different in stable patients (groups 1 and 2, 64 patients, 3% mortality) and in unstable patients (group 3, 34 patients, 59% mortality). A multivariate logistic regression analysis showed that the TTE results were not predictive of the risk of death. Conversely, the same analysis showed that the presence of metabolic acidosis was a powerful predictor of death.


CONCLUSIONS
Because none of the TTE measurements in ACP could be used to stratify the severity of MPE, TTE was of no help in deciding on medical thrombolysis. However, depending on its severity, metabolic acidosis could justify a large cooperative study to assess the impact of thrombolytic therapy on mortality rate in this specific group.
Vieillard-Baron
A
A
Medical Intensive Care Unit, University Hospital Ambroise Paré, Assistance Publique Hôpitaux de Paris, 9 avenue Charles de Gaulle, 92104, Boulogne Cedex, France.
Page
B
B
Augarde
R
R
Prin
S
S
Qanadli
S
S
Beauchet
A
A
Dubourg
O
O
Jardin
F
F
D000138:Acidosis / Q000209:etiology; D000208:Acute Disease; D000368:Aged; D017548:Echocardiography, Transesophageal / Q000592:standards; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005602:France / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D011655:Pulmonary Embolism / Q000145:classification / Q000150:complications* / Q000188:drug therapy; D011660:Pulmonary Heart Disease / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology* / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume
D005343:Fibrinolytic Agents