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JACC: CARDIOVASCULAR IMAGING © 2011 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.

VOL. 4, NO. 8, 2011 ISSN 1936-878X/$36.00 DOI:10.1016/j.jcmg.2011.04.013

CT Signs of Right Ventricular Dysfunction
Prognostic Role in Acute Pulmonary Embolism
Doo Kyoung Kang, MD,*†‡ Christian Thilo, MD,*†§ U. Joseph Schoepf, MD,*† J. Michael Barraza, JR, BS*† John W. Nance, JR, MD*† Gorka Bastarrika, MD, PHD,*† Joseph A. Abro, MA,*† James G. Ravenel, MD,† Philip Costello, MD,† Samuel Z. Goldhaber, MD¶ Charleston, South Carolina; Suwon, South Korea; Augsburg, Germany; Pamplona, Spain; and Boston, Massachusetts

O B J E C T I V E S The purpose of this study was to compare the prognostic role of various computed

tomography (CT) signs of right ventricular (RV) dysfunction, including 3-dimensional ventricular volume measurements, to predict adverse outcomes in patients with acute pulmonary embolism (PE).
B A C K G R O U N D Three-dimensional ventricular volume measurements based on chest CT have become feasible for routine clinical application; however, their prognostic role in patients with acute PE has not been assessed. M E T H O D S We evaluated 260 patients with acute PE for the following CT signs of RV dysfunction obtained on routine chest CT: abnormal position of the interventricular septum, inferior vena cava contrast reflux, right ventricle diameter (RVD) to left ventricle diameter (LVD) ratio on axial sections and 4-chamber (4-CH) views, and 3-dimensional right ventricle volume (RVV) to left ventricle volume (LVV) ratio. Comorbidities and fatal and nonfatal adverse outcomes according to the MAPPET-3 (Management Strategies and Prognosis in Pulmonary Embolism Trial-3) criteria within 30 days were recorded. R E S U L T S Fifty-seven patients (21.9%) had adverse outcomes, including 20 patients (7.7%) who died within 30 days. An RVDaxial/LVDaxial ratio 1.0 was not predictive for adverse outcomes. On multivariate analysis (adjusting for comorbidities), abnormal position of the interventricular septum (hazard ratio [HR]: 2.07; p 0.007), inferior vena cava contrast reflux (HR: 2.57; p 0.001), RVD4-CH/LVD4-CH ratio 1.0 (HR: 2.51; p 0.009), and RVV/LVV ratio 1.2 (HR: 4.04; p 0.001) were predictive of adverse outcomes, whereas RVD4-CH/LVD4-CH ratio 1.0 (HR: 3.68; p 0.039) and RVV/LVV ratio 1.2 (HR: 6.49; p 0.005) were predictive of 30-day death. C O N C L U S I O N S Three-dimensional ventricular volume measurement on chest CT is a predictor of early death in patients with acute PE, independent of clinical risk factors and comorbidities. Abnormal position of the interventricular septum, inferior vena cava contrast reflux, and RVD4-CH/LVD4-CH ratio are predictive of adverse outcomes, whereas RVDaxial/LVDaxial ratio 1.0 is not. (J Am Coll Cardiol Img 2011;4:841–9) © 2011 by the American College of Cardiology Foundation

From the *Heart and Vascular Center, Medical University of South Carolina, Charleston, South Carolina; †Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina; ‡Department of Radiology, Ajou University School of Medicine, Suwon, South Korea; §Department of Cardiology, Herzzentrum AugsburgSchwaben, Klinikum Augsburg, Augsburg, Germany; Department of Radiology, University of Navarra, Pamplona, Spain; and the ¶Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Dr. Schoepf receives research support from and is a consultant for Bayer-Schering, Bracco, General Electric, Medrad, and Siemens. Dr. Bastarrika is a consultant for General Electric, Medrad, and Siemens. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Kang and Thilo contributed equally to this work. Manuscript received March 29, 2011, accepted April 11, 2011.

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a total of 260 patients were included in the present analysis after 36 patients were excluded because of incomplete follow-up during the study period. diabetes mellitus. 3D assessment of right ventricular volume AUC area under the curve (RVV) and left ventricular volume (LVV) CI confidence interval may be more useful as a surrogate marker CT computed tomography for RV dysfunction in patients with acute ECG electrocardiogram PE. Adverse clinical outcomes were defined as death within 30 days or escalation of therapy. trauma in 32. Our study population included 172 patients (66. VOL. Six patients were excluded because of insufficient contrast enhancement of the ventricular chambers for reliable delineation of the endocardial borders. congestive heart failure. Forchheim. 160 mAseff. Contrast medium enhancement was achieved with 100 ml of a nonionic iodinated contrast medium (Ultravist 370. Chest CT procedures. stroke in 14. Image acquisition parameters consisted of 0. Wayne. New Jersey) injected at 4 ml/s using a power injector (Stellant D. Indianola. according to the MAPPET-3 (Management Strategies and Prognosis in Pulmonary Embolism Trial-3) study criteria (4). and measurements of RV diameter (RVD) divided by left ventricular diameters (LVD) on transverse chest CT sections or reconstructed 4-chamber (4-CH) views.5%) were inpatients already hospitalized at the time of acute PE diagnosis.9) and because of the only limited incremental diagnostic improvement over routine non–ECG-gated chest CT (23). Several studies have evaluated chest CT signs for determining the severity of RV dysfunction and for predicting patient outcome (10 –31). All patients included in this study were hemodynamically stable and had undergone a clinical assessment of the probability of PE.606 contrast-enhanced chest CT studies for suspected PE. chest computed tomography (CT) has become the preferred imaging modality for PE diagnosis in stable patients. From April 2007 through Au- R gust 2009 we performed 1. However. the purpose of this current investigation was to compare. A previous IVC inferior vena cava study (15) demonstrated that ventricular LV left ventricle volume measurements at electrocardioLVD left ventricular diameter gram (ECG)-gated chest CT were more LVV left ventricular volume sensitive for identifying patients with posPE pulmonary embolism sible RV dysfunction than diameter meaRV right ventricle surements on non–ECG-gated chest CT. Demographic information (age and sex) and medical history (history of cancer.onlinejacc. routine ECG-gating of chest diameter CT studies for diagnosing PE is not curRVV right ventricular volume rently recommended because of the additional radiation exposure involved with ECG-gated techniques (8. Adverse clinical outcomes. including flattening or displacement of the interventricular septum toward the left ventricle. or surgical embolectomy. sepsis in 11. Of these. 173 patients (66. 120 kV. 2011 AUGUST 2011:841–9 ight ventricular (RV) failure is the most common cause of early death among patients with acute pulmonary embolism (PE) (1–5).842 Kang et al. pneumonia in 29.9). acute PE. RVD right ventricular However. non–ECG-gated chest CT with all other described chest CT signs of RV dysfunction. and multisystem organ failure in 1 patient.5– 7).2. using the original Wells scoring system (34). Medrad.org/ on 01/28/2013 . and renal insufficiency) were recorded on the basis of patients’ medical records. myocardial infarction in 2. reflux of contrast material into the inferior vena cava (IVC). Prognostic Value of CT Signs of RV Dysfunction JACC: CARDIOVASCULAR IMAGING. Pennsylvania). pitch of 1. in patients with acute PE.8%) with abnormal D-dimer test. Primary reasons for hospitalization and complications other than acute PE during the hospital stay included major surgery in 93 patients. In all. major hemorrhage in 9. vasopressors for systemic hypotension. 8. 4. All patients had undergone non–ECG-gated chest CT on a 64-slice multidetector-row CT system (Somatom Sensation 64. Bayer-Schering. Automated bolus triggering was used with a region of interest in the main Downloaded From: http://imaging. For indicating imaging work-up of suspected PE. METHODS Patient population. Image post-processing methods en4-CH four-chamber abling 3D volumetry of the ventricles have recently become available. Siemens. (33). thrombolysis.2%) with a Wells score 4 and 88 patients (33. and a reconstructed section thickness of 1 mm. and 302 of these studies were interpreted as positive for new onset. coronary artery disease. because it is accurate and available 24 h daily at most institutions (8. the prognostic value for adverse outcomes and 30-day mortality of 3D volumetric ventricular analysis based on routine. Germany). While bedside echocardiography remains the first-line test for diagnosing RV dysfunction (3. because the ventricles have a ABBREVIATIONS AND ACRONYMS complex 3-dimensional (3D) shape. NO. Accordingly. chronic lung disease. our institution generally follows the recommendations as outlined by the Christopher Study Investigators (32) and by Piazza et al. endotracheal intubation. including cardiopulmonary resuscitation.6 mm collimation.

were identified. In a pilot investigation (21). 1B). Downloaded From: http://imaging. for the RV and LV. and septal bowing (convex toward the left ventricle) (25). The 3D volumetric analysis of both ventricles was performed by using the volume analysis application of the workstation (Volume Analysis. The degree of reflux was grouped into nonsubstantial (grades 1 to 3) and substantial (grades 4 to 6). Deviation of the interventricular septum was evaluated as follows: normal (convex toward the RV). perpendicular to the long axis of the heart.org/ on 01/28/2013 . SEPTAL BOWING. Next.onlinejacc. Siemens).K. All CT studies were reviewed and analyzed on a clinical workstation (MultiModality Workplace. a 4-chamber (4-CH) view reconstruction of a chest computed tomography scan shows septal flattening (arrows). Measurements of (E) maximal RVD and (F) LVD on 4-CH views show RVD4-CH/LVD4-CH ratio of 1. The patient required mechanical ventilation on the first day of her hospital stay and died on day 28. In case of multiple CT examinations for serial follow-up. 5 reflux into IVC and hepatic veins down to the mid-portion of the liver. RVV/LVV RATIO. 4. respectively. chest CT studies of 50 consecutive patients had been independently reviewed by 2 experienced observers (D. 1 no reflux.T. C. 1 and 2).98. Flattened septum (Fig.12.. and RVD4-CH/LVD4-CH ratios were calculated. (B) There is also grade 4 reflux of contrast medium into the inferior vena cava (long arrow) and proximal hepatic veins (short arrows). 2 trace of reflux into IVC only. 2A) were considered abnormal positions of the septum indicating RV strain. Prognostic Value of CT Signs of RV Dysfunction 843 pulmonary artery and a threshold of 100 Hounsfield units for initiating data acquisition. 1A) and septal bowing (Fig. Computed Tomography Signs of RV Dysfunction in a 77-Year-Old Woman (A) In a 77-year-old woman with acute pulmonary embolism. Measurements of (C) maximal right ventricular diameter (RVD) and (D) left ventricular diameter (LVD) on axial sections show RVD axial/LVD axial ratio of 0.K. VOL.K. 2011 AUGUST 2011:841–9 Kang et al. Observers were blinded to the patients’ clinical characteristics. Siemens). NO. Chest CT interpretation. RVDaxial and LVDaxial were subsequently measured.) for analysis of interobserver variability. IVC REFLUX. 4-CH views were reconstructed on the workstation using our previously described approach (21.62. 8. flattened. The remaining 210 patients were evaluated by 1 of the observers (D. we included only the first CT study performed at the time of the initial presentation. and the RVDaxial/LVDaxial ratio was calculated (Figs.JACC: CARDIOVASCULAR IMAGING. RVD/LVD RATIO. 6 reflux into IVC with opacification of distal hepatic veins (Fig. Semiautomated right ventricle volumetry (RVV) (purple) and left ventricle volumetry (LVV) (orange) displayed (G) on axial section and (H) on sagittal reformation shows RVV/LVV ratio of 1. The 2 axial sections that showed the maximal distance between the ventricular endocardium and the interventricular septum. The endocardial contours were semiautomatically segmented from the valvular The severity of reflux of contrast medium into the IVC or hepatic veins was graded according to a previously published scale (12): Figure 1. 3 reflux into IVC but not hepatic veins. 4 reflux into IVC and proximal hepatic veins.).26).K.

05) predictors of adverse outcomes and 30-day death. Belgium) for all statistical analyses. 2011 AUGUST 2011:841–9 Figure 2. VOL. the area under the curve (AUC) of RVDaxial/ LVDaxial.9 min (21). 4.4%) had relevant comorbidities. chronic interstitial lung disease in 26. (B) There is no contrast reflux into the inferior vena cava. MedCalc Software. NO. 8. convex toward the left ventricle. The patient died on hospital day 4. RVD4-CH/LVD4-CH. The mean age of the patient population was 55 18 years. weighted for higher sensitivity.4. the initial clinical diagnosis of PE was confirmed by the presence of at least 1 filling defect in the pulmonary artery tree (8. a 4-chamber (4-CH) view reconstruction of a chest computed tomography scan shows septal bowing (arrows). The RVV/LVV ratio was subsequently calculated (Figs. We used MedCalc (version 10.org/ on 01/28/2013 . [35]). We used the chi-square test or Fisher exact test for comparisons of categorical variables and the Mann-Whitney test for comparisons in the distributions of continuous variables.97.4. The Cox proportional hazard model was used to calcu- late the hazard ratio of clinical variables and CT measurements for predicting adverse outcomes. and renal insufficiency in 36. which were then automatically propagated to the neighboring sections.onlinejacc. Each CT sign was evaluated in a separate model accounting for clinical characteristics and comorbidities that were significant (p 0. Prognostic Value of CT Signs of RV Dysfunction JACC: CARDIOVASCULAR IMAGING. including cancer in 59. and there were 139 (53. congestive heart failure in 13. The time needed to perform the volumetric measurements ranged between 3. plane down to the apex of both ventricles.7 min and 10. Using receiver-operator characteristic curves (in accordance with the methods of DeLong et al. Mariakerke. Statistical analysis. 1 and 2).5%) men. diabetes mellitus in 40. That involved manually outlining the endocardial contours on the transverse sections comprising the minimal and maximal expanse of the ventricle. In all patients. using the proportional hazards model with calculation of 95% confidence intervals (CIs). for the above ratios were assigned.844 Kang et al.54. Measurements of maximal (E) RVD and (F) LVD on 4-CH views show RVD4-CH/LVD4-CH ratio of 1.9). coronary artery disease in 35. RESULTS Clinical characteristics of study population. One hundred forty-five patients (71. and optimal cutoff values. Multivariate analysis was then performed to identify predictors of adverse outcomes.8.28). Semiautomated right ventricle volumetry (RVV) (purple) and left ventricle volumetry (LVV) (orange) displayed (G) on transverse section and (H) on coronal reformation show an RVV/LVV ratio of 1. Computed Tomography Signs of RV Dysfunction in a 69-Year-Old Man (A) In a 69-year-old man with acute pulmonary embolism. similar to previous investigations (26. these cutoffs were used for subsequent analyses. and RVV/LVV for predicting adverse events and 30-day death were compared. Measurements of (C) maximal right ventricular diameter (RVD) and (D) left ventricular diameter (LVD) on axial sections show RVDaxial/LVDaxial ratio of 0. There were no statistical differences between the demographics or CT findings of the 36 ex- Downloaded From: http://imaging.

9%) had adverse clinical outcomes.3%) 10 (4.5%) 8 (14. RVD4-CH/ LVD4-CH.717). NO.659 (95% CI: 0. RVD4-CH/LVD4-CH ratio.0%) 14 (24.8%) 1 (1. 35 required endotracheal intubations. and 0.0.298 SD 59 16 34 (59.940).148 0.694 (95% CI: 0. with moderate reproducibility (k 0.JACC: CARDIOVASCULAR IMAGING.9%) 7 (3. RVD4-CH/LVD4-CH 1.021* 0.0%) 3 (15.org/ on 01/28/2013 .698 (95% CI: 0.603 to 0.0%) 4 (20.0%) 7 (35.598 to 0. Correlation coefficients for measurements of RVDaxial/LVDaxial ratio.6%) 24 (10. Clinical Characteristics and Comorbidities of Patients Who Died Versus Patients Who Survived Death (n 20) Age.0%) Downloaded From: http://imaging.636 0.0%) 1 (5. and RVV/LVV 1.603 to 0.8%) 23 (9.677 (95% CI: 0.0%) 1 (5.565 to 0.433 0.038* 1.001* 0.7%) who died within 30 days.0%) 1 (5. 0.077 0.0. mean Men Within 30 days before PE diagnosis Major surgery Pneumonia Sepsis Trauma Stroke Major hemorrhage Myocardial infarction Multisystem organ failure Comorbidities Cancer Coronary artery disease Congestive heart failure Diabetes mellitus Chronic lung disease Renal insufficiency *Statistically significant p value.6%) 5 (8.4%) 0 (0. Prognostic value of CT signs.0%) 124 (51.000 0.6 days) from the time of diagnosis. respectively.515 1.634 to 0.7%) 87 (36.9%) 0. Interobserver reproducibility.001* SD 61 15 15 (75.3%) 1 (0.391 0. renal insufficiency.2 as optimal cutoffs with high sensitivity ( 70%) for predicting 30-day death. Survival (n 240) 54 17 p Value 0.617 to 0.219 0.734).8%) 21 (10.061 0.05 for all measures).93 respectively (p 0.4%) 1 (0.8%) 4 (7. 4.755 0. 2011 AUGUST 2011:841–9 Kang et al.9%) 10 (4.32). and AUCs of 0.0%) 2 (3.0%) 12 (60. whereas cancer.001* 0. Prognostic Value of CT Signs of RV Dysfunction 845 cluded patients and final study population (p 0.7%) 26 (12.5%) 0 (0.020* 0.44) for differentiating normal versus abnormal (i.5%) 19 (9.064 0.8%) 4 (7.7%) 19 (33.4%) 6 (2.000 0.519 0.096 0. diabetes mellitus.937). No Adverse Outcome (n 203) 54 18 p Value 0. PE pulmonary embolism.8%) 31 (12.0%) 0 (0.8%) 20 (35. 0.3%) 25 (10. 7 required cardiopulmonary resuscitation.3%) 10 (17.88.715). Receiveroperator characteristic analysis identified RVDaxial/ LVDaxial 1. Adverse outcomes occurred in the range from 1 day to 30 days (mean 10.e.519 0.5%) 31 (12.4%) 26 (12. Clinical Characteristics and Comorbidities in Patients With and Without Adverse Outcomes Adverse Outcome (n 57) Age. Fifty-seven patients (21.3%) 9 (15.610 0.597 to 0.5%) 23 (11. these parameters were subsequently included in the relevant multivariate analyses. yrs.8%) 9 (4.068 0. and 0. flattening or bowing) position.8%) 15 (26.8%) 8 (3.9%) 14 (5.023* 0. and 0. and RVV/LVV with AUCs of 0.001* specificities of CT signs for predicting adverse outcomes and 30-day death are presented in Table 4.750).0%) 3 (15. yrs. 15 were treated with vasopressors.001 for all correlations).490 0. There was good agreement (k 0.0%) 5 (25. 11 received thrombolysis.658 (95% CI: 0.477 0.0%) 1 (5. for predicting 30-day death (p 0.2%) 33 (13.0%) 4 (20.664 (95% CI: 0. The pilot investigation (21) in 50 patients had shown fair interobserver reproducibility for describing the position of the ventricular septum (k 0.255 0..2%) surviving patients with adverse outcomes. and RVV/LVV ratio measurements between the 2 observers were 0.85. VOL. renal insufficiency. Table 2.0%) 9 (15.68) for classifying the degree of contrast medium reflux into the IVC and hepatic veins as nonsubstantial versus substantial.324 0. 8. respectively. mean Men Within 30 days before PE diagnosis Major surgery Pneumonia Sepsis Trauma Stroke Major hemorrhage Myocardial infarction Multisystem organ failure Comorbidities Cancer Coronary artery disease Congestive heart failure Diabetes mellitus Chronic lung disease Renal insufficiency *Statistically significant p value.3%) 16 (7.366 0.484 0. 0.onlinejacc.0%) 50 (20. for predicting adverse events (p 0. these values were used for subsequent analyses. Of the 37 (14. Patients with adverse outcomes were older and more commonly had diabetes mellitus.0%) 9 (45. There were no differences in the AUC of RVDaxial/LVDaxial.4%) 3 (1. and 4 underwent surgical embolectomy.0%) 44 (21. and sepsis were more common among patients who died within 30 days (Table 2). and sepsis (Table 1).753).1%) 74 (36.0%) 6 (30. PE pulmonary embolism. Table 3 illustrates the prevalence of the measured CT signs in patients with and without adverse events and 30-day death.4 9. including 20 (7.638 to 0.721).6%) 105 (51.5%) 1 (1. The sensitivities and Table 1.

2011 AUGUST 2011:841–9 Table 3. The routine availability of contemporary advanced image post-processing workstations.006* 0.8% (91/203) 44.9%) 9 (45.0 Death (n 20) No Adverse Outcomes (n 203) Survival (n 240) p Value 0. However.3%) survived.0% (17/20) 78.84.8% (158/240) 85. with hazard ratios of 3. while RVD4-CH/LVD4-CH 1.20. Several studies reported that ventricular septal bowing indicated severe PE (13. RVD4-CH/LVD4-CH 1.2% (36/57) 75% (15/20) 78.3%).0%) 22 (38. (31). In our cohort. Ghaye et al. Conversely. RVV right ventricular volume.60.9% (29/57) 45% (9/20) 38.25) as manifested by RV dysfunction (14. In our cohort. is acute RV failure (1. most deaths in PE patients occur because of pre-existing underlying disease (37). and Aviram et al.2%) 15 (75. and the risk of death within 30 days increased approximately 6-fold.0.104 0.37).0% (17/20) 44.6% (95/240) 48. NO.039) and 6. Van der Meer et al. 45 (30. where abnormal position of the Downloaded From: http://imaging.77 to 23.2 For predicting adverse outcomes For predicting 30-day death Values are % (n/N).0 and RVV/LVV were predictive of 30-day death.9%) 17 (85.031* 0. The interventricular septum.4% (86/203) 39.009* value of 30. namely.2%) and 108 survived (negative predictive value 97. overall.4%) 117 (57. has greatly facilitated the performance of 3D ventricular volume measurement. RVD right ventricular diameter.2 were independent predictors of adverse events. may shift toward the LV related to increased right-side heart pressure with severe pulmonary arterial obstruction (16).355 0. within 30 days as in our study.org/ on 01/28/2013 .2%) 133 (55. most patients (97. LVD left ventricular diameter. and RVV/LVV 1.8% (194/240) We show that 3D measurement of ventricular volumes is superior to other chest CT signs of RV dysfunction for predicting adverse outcomes and 30-day death in patients with acute PE.2%) had adverse events within 30 days.001* 0. and 17 died (positive predictive value of 11. LVV left ventricular volume. The proportion of patients who had nonfatal in-hospital adverse events or required escalation of therapy was similar to that in the MAPPET-3 study (4).22) and predicted short-term death (10). which automatically propagate the segmentation of cardiac chambers.7% (174/203) 80.0 was not independently predictive of adverse outcomes or 30-day death. Computed Tomography Signs of Right Ventricular Dysfunction for Predicting Adverse Outcomes and 30-Day Death Adverse Outcomes (n 57) CT Sign of RV Dysfunction Abnormal position of septum IVC contrast reflux RVDaxial/LVDaxial RVD4-CH/LVD4-CH RVV/LVV 1. which normally bows toward the RV. The patients enrolled in our study suffered from a variety of severe diseases and may therefore have died of other reasons than PE.2.6%) 145 (60.2 1. in the absence of an RVV/LVV ratio 1.0 63. Sensitivity Specificity 50. and thus was very similar to the mortality rates in other studies (3. Abnormal position of the interventricular septum.2%) 29 (14. substantial IVC contrast reflux.005).5. Among 111 patients with RVV/ LVV 1.0% (108/240) For predicting adverse outcomes For predicting 30-day death RVD4-CH/LVD4-CH 1. Prognostic Value of CT Signs of RV Dysfunction JACC: CARDIOVASCULAR IMAGING.5%) 82 (34. Sensitivity and Specificity Values of CT Signs for Predicting Adverse Outcome and 30-Day Death CT Sign of RV Dysfunction Abnormal position of septum For predicting adverse outcomes For predicting 30-day death IVC contrast reflux For predicting adverse outcomes For predicting 30-day death RVDaxial/LVDaxial 1.6% (22/57) 25.2%).36. 4-CH 4-channel.0%) 62 (30.001* 0. p 0. These latter findings correspond to our current results.0 For predicting adverse outcomes For predicting 30-day death RVV/LVV 1. (12) did not find this sign to be predictive of death from acute PE.08 to 12.0 1.2.0%) 45 (78.9% (45/57) 85. Conversely.3%) 46 (19. 45 had adverse events within 30 days (representing a positive predictive Table 4.0% (5/20) 69.6%) 5 (25.9%) 17 (85. respectively (Table 5).2. (11). CT computed tomography. Abbreviations as in Table 3. Araoz et al.onlinejacc. (17).014* 0. the mortality rate was 7. the main cause of early death. Among 149 patients with RVV/LVV ratio 1.0%) 36 (63.2.68 (95% CI: 1.8% (99/203) 45. 4.49 (95% CI: 1.558 0. 99 experienced no adverse events (negative predictive value 89.6% (107/240) 42.846 Kang et al. although. Multivariate analysis demonstrated that RVDaxial/ LVDaxial 1. RV right ventricular.9% (45/57) 85. This evaluation method may more appropriately account for the complex shape of the cardiac ventricles than a single image or plane. DISCUSSION 29 (50. p 0.0%) Values are n (%). IVC inferior vena cava.3).338 0. VOL. 8.2%) 112 (55. Performing 3D volumetric ventricular measurements can be accomplished on most current image post-processing platforms. among 149 patients with RVV/LVV ratio 1.7% within 30 days.2%) 132 (55.0%) 45 (78.4%).4%) 104 (51.5% (141/203) 65.

28). Increased RVD/LVD ratio on chest CT has been proposed as a sign of RV dysfunction. (10) and Contractor et al.2622–4. Reflux of contrast medium into the IVC is an indirect sign of increased RV pressure and can be seen in various underlying conditions (21).onlinejacc. renal insufficiency.001* 0. we chose not to formally analyze this small subset of our patients.264 29 9 2.4688–4. Cancer. because the images are acquired in different phases of the cardiac cycle. These findings correspond to our own prior investigations (26. (31) used maximum minor axis measurements.JACC: CARDIOVASCULAR IMAGING.667 of RVDaxial/LVDaxial 0. Dogan et al. Multivariate Analysis of CT Signs for Predicting Adverse Outcomes and 30-Day Death Multivariate Analysis CT Sign of RV Dysfunction Abnormal position of septum For predicting adverse outcomes For predicting 30-day death IVC contrast reflux For predicting adverse outcomes For predicting 30-day death RVDaxial/LVDaxial 1. Study limitations.6361–5. (14) and Lim et al. (14) measured both ventricles at the level of the atrioventricular valves. Prognostic Value of CT Signs of RV Dysfunction 847 interventricular septum was overall predictive of adverse events but not of 30-day death.7948–2.753 of RVD4-CH/LVD4-CH 0. multiple quantitative methods and cutoff points have been described to assess dilatation of the complex-shaped RV in patients with acute PE.1192 0.27).20.0 vs. is identical to the RVD/LVD cutoff of 1.5164 0. while others proposed a threshold of 1.5%) had echocardiography findings available. However. and sepsis were statistically significant (p 0.070 n HR 95% CI p Value Age. it failed to identify patients at risk of early death. 0.2864 0. Although a recent report (30) described no statistically significant difference between measurements of RV enlargement on axial and 4-CH views. we did not include patients without PE as a control group to determine whether these findings are unique to PE positive patients. The most important limitation of our study is its retrospective nature. with an AUC of 0. although RVDaxial/LVDaxial 1. ventricular measurements on 4-CH views were superior. diabetes mellitus.05) predictors of 30-day death and included in the relevant multivariate analysis.007* 0. where we found that the proportion of patients with increased RVDaxial/LVDaxial ratios on transverse sections was similar for patients with and without adverse events. Several studies report that an increased RVDaxial/ LVDaxial ratio on transverse chest CT sections indicates RV dysfunction (14. whereas van der Meer et al.0 36 15 45 17 45 17 1. More im- Downloaded From: http://imaging.4158 2.005* For predicting adverse outcomes For predicting 30-day death RVD4-CH/LVD4-CH 1. (22) found a RVDaxial/LVDaxial ratio of 1 as measured on transverse sections indicative of severe PE.0 For predicting adverse outcomes For predicting 30-day death RVV/LVV 1. (15) reported significant differences for RVD4-CH/LVD4-CH ratios between patients with and without PE but not for RVDaxial/LVDaxial ratios on transverse sections.8337 1.9970–8.22) and predicts short-term death (10). HR hazard ratio. renal insufficiency. *Statistically significant p value.5032 0. this parameter was neither predictive of adverse outcomes overall nor of early death. the use of ECG-gated CT protocols over routine chest CT has been shown to result in only limited incremental diagnostic improvements (23). CI confidence interval. 8. which.240 0. for predicting adverse outcomes. our current investigation is 1 of the largest analyses to date evaluating the prognostic value of chest CT signs of RV dysfunction in patients with acute PE.20. VOL.039* 0. Also. however.5 (13.2216–3.0726 2. NO.0771–12.05) predictors of adverse events and subsequently included in the relevant multivariate analysis.5084 3.5718 1.5994 1. Non–ECG-gated CT is inevitably inaccurate for measuring ventricular chamber size.26). 4.5221 0.8402 0. receiver-operator characteristic analysis in our current investigation revealed a slightly higher RVD4-CH/LVD4-CH ratio cutoff (1. Table 5.1646 1.3919 1. unfortunately. only a small percentage of our patients (100 of 260.6839 4. Our study would have been strengthened by correlation with echocardiography findings.24. It is the only study systematically comparing all signs that have been described for this purpose. and sepsis were statistically significant (p 0. However. However.4919 0.22. 2011 AUGUST 2011:841–9 Kang et al.171 0.9339 1.7325–5.9349–6. While substantial IVC reflux was predictive of adverse outcomes in our study. Contractor et al.9.2 For predicting adverse outcomes For predicting 30-day death 22 5 2. including the rather recent method of 3D ventricular volumetry. However. In our current investigation.9).7678–23.9 versus an AUC of 0.0 used in the MAPPET-2 trial (3) and the PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) II study (38).0848 2. although others found this sign not to be associated with increased mortality in stable patients without shock (29). Another potential limitation of our present study is that chest CT image acquisition was not ECG gated.0 was more common in patients who died within 30 days. Considering that prior studies have established a good correlation between echocardiography and CT findings (18. Araoz et al.28). other abbreviations as in Table 3. Compared with our previous studies (26.0379 6.009* 0.9850 1. 38.org/ on 01/28/2013 .001* 0. diabetes mellitus.

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