Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

doi:10.5847/wjem.j.1920-8642.2021.04.002

Abstract

Abstract:

BACKGROUND: There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study.
METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis.
RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively).
CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.

Key words: Main pulmonary artery, Pulmonary embolism, Computerized tomography pulmonary arteriography

Dong Jia, Chao Ji, Min Zhao. Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study[J]. World Journal of Emergency Medicine, 2021, 12(4): 261-267.

Figures/Tables 5

Figure 1.

Table 1

Table 2

Prognostic factors associated with deterioration

Variables	Univariate		Multivariate
Variables	HR (95% CI)	P-value	HR (95% CI)	P-value
MPA embolism to non-MPA embolism, n=306 (153:153)
MPA embolism	2.13 (1.10-4.12)	0.025^*	1.96 (1.01-3.83)	0.047^*
Saddle MPA embolism	1.75 (0.83-3.68)	0.140	-	-
Bova score II	1.64 (0.75-3.58)	0.220	0.57 (0.22-1.44)	0.230
Bova score III	5.17 (2.51-10.65)	<0.001^*	1.51 (0.61-3.74)	0.370
Risk stratification (intermediate-low risk)	1.35 (0.43-4.17)	0.610	1.45 (0.46-4.54)	0.520
Risk stratification (intermediate-high risk)	5.28 (2.19-12.76)	<0.001^*	5.85 (1.98-17.30)	0.001^*
Non-saddle MPA embolism to non-MPA embolism,n=220 (110:110)
MPA embolism	2.33 (1.06-5.12)	0.034^*	2.34 (1.07-5.15)	0.034^*
Saddle MPA embolism	-	-	-	-
Bova score II	2.22 (0.84-5.83)	0.011^*	0.97 (0.31-3.03)	0.950
Bova score III	6.93 (2.99-16.06)	<0.001^*	2.80 (0.92-8.54)	0.070
Risk stratification (intermediate-low risk)	3.99 (0.99-15.95)	0.050	3.72 (0.91-14.25)	0.068
Risk stratification (intermediate-high risk)	9.30 (2.76-31.30)	<0.001^*	5.99 (1.36-26.45)	0.018^*
Saddle MPA embolism to non-saddle MPA embolism,n=147 (49:98)
MPA embolism	-	-	-	-
Saddle MPA embolism	1.13 (0.57-2.23)	0.720	-	-
Bova score II	1.28 (0.50-3.31)	0.610	0.67 (0.21-2.09)	0.490
Bova score III	4.00 (1.88-8.49)	<0.001^*	1.85 (0.63-5.43)	0.260
Risk stratification (intermediate-low risk)	2.01 (0.52-7.76)	0.310	2.12 (0.54-8.42)	0.280
Risk stratification (intermediate-high risk)	4.92 (1.49-16.25)	0.009^*	3.94 (0.87-17.73)	0.074
Saddle MPA embolism to non-MPA embolism, n=153 (51:102)
MPA embolism	-	-	-	-
Saddle MPA embolism	1.90 (0.93-3.87)	0.080	1.92 (0.93-3.99)	0.079
Bova score II	1.79 (0.71-4.51)	0.220	0.60 (0.21-1.72)	0.340
Bova score III	6.72 (2.82-16.00)	<0.001^*	1.99 (0.71-5.53)	0.190
Risk stratification (intermediate-low risk)	1.26 (0.21-7.57)	0.800	1.21 (0.20-7.38)	0.830
Risk stratification (intermediate-high risk)	6.97 (1.65-29.42)	0.008^*	7.06 (1.38-36.09)	0.019^*

Table 2

Figure 2.

Figure 3.

References 23

1	Beenen LFM, Bossuyt PMM, Stoker J, Middeldorp S. Prognostic value of cardiovascular parameters in computed tomography pulmonary angiography in patients with acute pulmonary embolism. Eur Respir J. 2018; 52(1):1702611. doi: 10.1183/13993003.02611-2017
2	Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019; 54(3):1901647. doi: 10.1183/13993003.01647-2019
3	Santos AR, Freitas P, Ferreira J, Oliveira A, Goncalves M, Faria D, et al. Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate-high risk subgroup. Eur Heart J Acute Cardiovasc Care. 2020; 9(4):279-85. doi: 10.1177/2048872619846506
4	Rivera-Lebron BN, Rali PM, Tapson VF. The PERT concept: a step-by-step approach to managing pulmonary embolism. Chest. 2021; 159(1):347-55. doi: 10.1016/j.chest.2020.07.065
5	Zuin M, Rigatelli G, Zonzin P, Casazza F, Roncon L. Saddle pulmonary embolism in hemodynamically stable patients: to lyse or not to lyse? An issue in no guidelines land. Eur J Intern Med. 2017; 46:e26-e28. doi: 10.1016/j.ejim.2017.09.002
6	Fernandez C, Bova C, Sanchez O, Prandoni P, Lankeit M, Konstantinides S, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015; 148(1):211-8. doi: 10.1378/chest.14-2551
7	Choi KJ, Cha SI, Shin KM, Lim JK, Yoo SS, Lee J, et al. Central emboli rather than saddle emboli predict adverse outcomes in patients with acute pulmonary embolism. Thromb Res. 2014; 134(5):991-6. doi: 10.1016/j.thromres.2014.08.027
8	Jia D, Li XL, Zhang Q, Hou G, Zhou XM, Kang J. A decision tree built with parameters obtained by computed tomographic pulmonary angiography is useful for predicting adverse outcomes in non-high-risk acute pulmonary embolism patients. Respir Res. 2019; 20(1):187. doi: 10.1186/s12931-019-1160-5
9	Zhou WH, He JQ, Guo SG, Walline J, Liu XY, Tian LY, et al. Venous thromboembolism in the emergency department: A survey of current best practice awareness in physicians and nurses in China. World J Emerg Med. 2019; 10(1):5-13. doi: 10.5847/wjem.j.1920-8642.2019.01.001
10	Liu M, Miao R, Guo X, Zhu L, Zhang H, Hou Q, et al. Saddle pulmonary embolism: laboratory and computed tomographic pulmonary angiographic findings to predict short-term mortality. Heart Lung Circ. 2017; 26(2):134-42. doi: 10.1016/j.hlc.2016.02.019
11	Pruszczyk P, Pacho R, Ciurzynski M, Kurzyna M, Burakowska B, Tomkowski W, et al. Short term clinical outcome of acute saddle pulmonary embolism. Heart. 2003; 89(3):335-6. pmid: 12591851
12	Alkinj B, Pannu BS, Apala DR, Kotecha A, Kashyap R, Iyer VN. Saddle vs non-saddle pulmonary embolism: clinical presentation, hemodynamics, management, and outcomes. Mayo Clin Proc. 2017; 92(10):1511-1518. doi: 10.1016/j.mayocp.2017.07.014
13	Sardi A, Gluskin J, Guttentag A, Kotler MN, Braitman LE, Lippmann M. Saddle pulmonary embolism: is it as bad as it looks? A community hospital experience. Crit Care Med. 2011; 39(11):2413-8. doi: 10.1097/CCM.0b013e31822571b2
14	Peng Z, Wei M, Chen S, Lin M, Jiang C, Mei J, et al. Combined transcatheter arterial chemoembolization and radiofrequency ablation versus hepatectomy for recurrent hepatocellular carcinoma after initial surgery: a propensity score matching study. Eur Radiol. 2018; 28(8):3522-31. doi: 10.1007/s00330-017-5166-4
15	Gong ZJ, Cheng JW, Gao PT, Huang A, Sun YF, Zhou KQ, et al. Clinical characteristics and prognostic factors of patients with intrahepatic cholangiocarcinoma with fever: a propensity score matching analysis. Oncologist. 2019; 24(7):997-1007. doi: 10.1634/theoncologist.2018-0268
16	Liu W, Zou R, Wang C, Qiu J, Shen J, Liao Y, et al. Microwave ablation versus resection for hepatocellular carcinoma within the Milan criteria: a propensity-score analysis. Ther Adv Med Oncol. 2019; 11:1758835919874652.
17	Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol. 2001; 176(6):1415-20. doi: 10.2214/ajr.176.6.1761415
18	Furlan A, Aghayev A, Chang CC, Patil A, Jeon KN, Park B, et al. Short-term mortality in acute pulmonary embolism: clot burden and signs of right heart dysfunction at CT pulmonary angiography. Radiology. 2012; 265(1):283-93. doi: 10.1148/radiol.12110802
19	Raslan IR, Brown P, Westerhout CM, Ezekowitz JA, Hernandez AF, Starling RC, et al. Characterization of hemodynamically stable acute heart failure patients requiring a critical care unit admission: Derivation, validation, and refinement of a risk score. Am Heart J. 2017; 188:127-35. doi: 10.1016/j.ahj.2017.03.014
20	Mukhopadhyay S, Johnson TA, Duru N, Buzza MS, Pawar NR, Sarkar R, et al. Fibrinolysis and inflammation in venous thrombus resolution. Front Immunol. 2019; 10:1348. doi: 10.3389/fimmu.2019.01348 pmid: 31258531
21	Matsuoka S, Kotoku A, Yamashiro T, Matsushita S, Fujikawa A, Yagihashi K, et al. Quantitative CT evaluation of small pulmonary vessels in patients with acute pulmonary embolism. Acad Radiol. 2018; 25(5):653-8. doi: S1076-6332(17)30500-7 pmid: 29331359
22	Hajizadeh R, Ghaffari S, Rajebi H, Kavandi H, Javanshir E, Fahimi G, et al. Short-term mortality of patients with saddle pulmonary embolism: a single-center study. Turk Kardiyol Dern Ars. 2019; 47(4):273-80. doi: 10.5543/tkda.2019.77292 pmid: 31219452
23	Schievano S, Capelli C, Young C, Lurz P, Nordmeyer J, Owens C, et al. Four-dimensional computed tomography: a method of assessing right ventricular outflow tract and pulmonary artery deformations throughout the cardiac cycle. Eur Radiol. 2011; 21(1):36-45. doi: 10.1007/s00330-010-1913-5 pmid: 20680286

Variables	With deterioration (n=70)	Without deterioration (n=657)	P-value
Age, years, mean±SD	59.91±15.29	59.71±15.72	0.920
Sex, male/female	38/32	328/329	0.490
Main pulmonary artery embolism (+/-),n (%)	43 (61.4)	135 (20.5)	<0.001
Saddle main pulmonary artery embolism (+/-), n (%)	14 (20.2)	37 (5.6)	<0.001
Bova I, n (%)	25 (35.7)	560 (85.2)	<0.001
Bova II, n (%)	16 (22.9)	70 (10.7)	0.002
Bova III, n (%)	29 (41.4)	27 (4.1)	<0.001
Risk stratification (low risk), n (%)	12 (17.1)	132 (20.1)	0.560
Risk stratification (intermediate-low risk), n (%)	11 (15.7)	131 (19.9)	0.400
Risk stratification (intermediate-high risk), n (%)	47 (67.1)	94 (14.3)	<0.001

[1]	Jian-ping Gao, Ke-jing Ying. Thrombolysis during extended cardiopulmonary resuscitation for autoimmune-related pulmonary embolism [J]. World Journal of Emergency Medicine, 2015, 6(2): 153-156.
[2]	Gulden Ozeren Yetgin, Sule Akkose Aydin, Ozlem Koksal, Fatma Ozdemir, Dilek Kostak Mert, Gokhan Torun. Clinical probability and risk analysis of patients with suspected pulmonary embolism [J]. World Journal of Emergency Medicine, 2014, 5(4): 264-269.
[3]	Ling-cong Wang, Rong-lin Jiang, Wei Zhang, Li-ling Wei, Ru-hui Yang. Effects of aspirin on the expression of nuclear factor-κB in a rat model of acute pulmonary embolism [J]. World Journal of Emergency Medicine, 2014, 5(3): 229-233.
[4]	Jing-xia Zhang, Yong-li Chen, Yu-ling Zhou, Qian-yu Guo, Xian-pei Wang. Expression of tissue factor in rabbit pulmonary artery in an acute pulmonary embolism model [J]. World Journal of Emergency Medicine, 2014, 5(2): 144-147.
[5]	Zehtabchi Shahriar, Rinnert Stephan, Malhotra Shweta, Subramanian Arun, Timberger Mathew, Patel Brijal, Toro David, Hassan Khaled, Sinert Richard. Could the number of CT angiograms be reduced in emergency department patients suspected of pulmonary embolism? [J]. World Journal of Emergency Medicine, 2012, 3(3): 172-176.