Associação do Nível de ST2 Solúvel com Mortalidade em 6 Meses e/ou Hospitalização Recorrente Relacionada a Doenças Cardiovasculares em Embolia Pulmonar / Association of soluble ST2 Level with 6-month Mortality and/or Recurrent Cardiovascular-Related Hospitalization in Pulmonary Embolism

Resumo Fundamento: A associação de supressão solúvel da tumorigênese-2 (sST2) com prognóstico em embolia pulmonar (EP) é desconhecida. Objetivo: Este estudo teve como objetivo investigar a relação entre os níveis de sST2 em pacientes com EP aguda e mortalidade em 6 meses e hospitalizações recorrentes. Métodos: Este estudo prospectivo incluiu 100 pacientes com EP aguda. Os pacientes foram classificados em dois grupos de acordo com a mortalidade em 6 meses e a presença de hospitalizações recorrentes relacionadas a doenças cardiovasculares. Dois grupos foram comparados. Um valor de p de 0,05 foi considerado estatisticamente significativo. Resultados: Os níveis de ST2 solúvel foram significativamente maiores no grupo com mortalidade e internações recorrentes. (138,6 ng/mL (56,7-236,8) vs. 38 ng/mL (26,3-75,4); p<0,001) O melhor limite de corte para níveis de sST2 na previsão de um desfecho composto de mortalidade em 6 meses e/ou a hospitalização recorrente relacionada a doenças cardiovasculares foi >89,9, com especificidade de 90,6% e sensibilidade de 65,2%, de acordo com a curva Receiver Operating Characteristic (área sob a curva = 0,798; IC 95%, 0,705-0,891; p <0,0001). Após ajuste para fatores de confusão que foram estatisticamente significativos na análise univariada ou para as variáveis correlacionadas com os níveis de sST2, nível de sST2 (OR = 1,019, IC 95%: 1,009-1,028, p 0,001) e proteína C reativa (PCR). (OR = 1,010, IC 95%: 1,001-1,021, p = 0,046) continuaram a ser preditores significativos de mortalidade em 6 meses e/ou hospitalização recorrente relacionada a doenças cardiovasculares no modelo de regressão logística múltipla através do método backward stepwise. Conclusões: O nível de ST2 solúvel parece ser um biomarcador para prever mortalidade em 6 meses e/ou hospitalização recorrente relacionada a doenças cardiovasculares em pacientes com EP aguda.

Abstract Background: The association of soluble suppression of tumorigenesis-2 (sST2) levels with prognosis in pulmonary embolism (PE) is unknown. Objective: This study aimed to investigate the relationship between sST2 levels in patients with acute PE and 6-month mortality and recurrent hospitalizations. Methods: This prospective study included 100 patients with acute PE. Patients were classified into two groups according to 6-month mortality and the presence of recurrent Cardiovascular-Related hospitalizations. Two groups were compared. A p-value of 0.05 was considered statistically significant. Results: Soluble ST2 levels were significantly higher in the group with mortality and recurrent hospitalizations. (138.6 ng/mL (56.7-236.8) vs. 38 ng/mL (26.3-75.4); p<0.001) The best cut-off threshold for sST2 levels in the prediction of a composite outcome of 6-month mortality and/or recurrent Cardiovascular-Related hospitalization was found to be >89.9 with a specificity of 90.6% and a sensitivity of 65.2%, according to the receiver operating characteristic curve (area under the curve = 0.798; 95% CI, 0.705-0.891; p <0.0001). After adjusting for confounding factors that were either statistically significant in the univariate analysis or for the variables correlated with the sST2 levels, sST2 level (OR = 1.019, 95% CI: 1.009-1.028, p 0.001) and C-reactive protein (CRP ) (OR = 1.010, 95% CI: 1.001-1.021, p = 0.046) continued to be significant predictors of 6-month mortality and/or recurrent Cardiovascular-Related hospitalization in the multiple logistic regression model via backward stepwise method. Conclusion: Soluble ST2 level seems to be a biomarker to predict 6-month mortality and/or recurrent Cardiovascular-Related hospitalization in patients with acute PE.

A mudança de paradigma no tratamento do tromboembolismo venoso grave / The paradigm shift in treatment of severe venous thromboembolism

Resumo A embolia pulmonar (EP) é a terceira maior causa de morte cardiovascular e a principal de morte evitável intra-hospitalar no mundo. O conceito PERT® (do inglês, pulmonary embolism response team) envolve seu diagnóstico e tratamento precoce e multidisciplinar. A trombose venosa profunda (TVP) é a sua causa inicial na maioria dos casos e é responsável por complicações como a recidiva tromboembólica, a síndrome pós-trombótica e a hipertensão pulmonar tromboembólica crônica. Uma abordagem inicial semelhante ao PERT nos casos de TVP ilíaco-femoral grave pode reduzir não apenas o risco imediato de EP e morte, mas também suas sequelas tardias. Novas técnicas percutâneas e aparatos de trombectomia mecânica para o tromboembolismo venoso (TEV) vêm demonstrando resultados clínicos encorajadores. Propomos o desenvolvimento de um conceito ampliado de resposta rápida ao TEV, que envolve não apenas a EP (PERT®) mas também os casos graves de TVP: o time de resposta rápida para o TEV (TRETEV®), ou do inglês Venous Thromboembolism Response Team (VTERT®).

Abstract Pulmonary embolism (PE) is the third leading cause of cardiovascular death and the main cause of preventable in-hospital death in the world. The PERT® (Pulmonary Embolism Response Team) concept involves multidisciplinary diagnosis and immediate treatment. Deep venous thrombosis (DVT) is the initial cause of most cases of PE and is responsible for complications such as chronic thromboembolic recurrence, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. An aggressive approach to severe cases of iliofemoral DVT similar to the PERT® system can not only reduce the immediate risk of PE and death but can also reduce later sequelae. New percutaneous techniques and mechanical thrombectomy devices for venous thromboembolism (VTE) have shown encouraging clinical results. We propose the development of an expanded concept of rapid response to VTE, which involves not only PE (PERT®) but also severe cases of DVT: the Venous Thromboembolism Response Team (VTERT®).

Infarto pulmonar: signos que no debemos dejar pasar en TC de tórax sin contraste / Pulmonary infarction: the signs that we must not miss in chest CT without contrast

Resumen El infarto pulmonar (IP) resulta de la oclusión de las arterias pulmonares distales que generan isquemia, hemorragia y finalmente necrosis del parénquima pulmonar, siendo la causa más frecuente la embolia pulmonar (EP). El diagnóstico oportuno de IP permite el inicio precoz del tratamiento y el respectivo manejo de sostén, disminuyendo así la morbimortalidad asociada. El objetivo de esta revisión es remarcar la importancia de identificar aquellos signos, que en la tomografía computada (TC) sin contraste son altamente sensibles y específicos para el diagnóstico de IP. La TC de alta resolución constituye el método que más información aporta, pudiendo observar signos clásicos de IP como la opacidad en forma de cuña, opacidad con radiolucencia central y el signo del vaso nutricio; así como signos con alto valor predictivo negativo para IP, como la opacidad consolidativa con broncograma aéreo, sugestivo de otras patologías, ya sean infecciosas o tumorales.

Abstract Pulmonary infarction (PI) results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage, and necrosis of the pulmonary parenchyma. The most common cause of pulmonary infarction is pulmonary embolism (PE). Early diagnosis of PI allows early initiation of treatment and supportive care, thus reducing the associated morbidity and mortality. This review aims to highlight the importance of identifying signs that are highly sensitive and specific for the diagnosis of PE even without IV contrast. High-resolution computed tomography (CT) is the method that provides the most information, as it observes classic signs of PI such as wedge-shaped opacity, central lucencies in peripheral consolidation, and the feeding vessel sign, as well as signs with high negative predictive value such as consolidating opacity with air bronchogram that are suggestive of other pathologies, whether infectious or tumoural.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura / Pulmonary embolism in infective endocarditis associated with pacemaker: report of a case and review of the literature

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Pulmonary embolism in pediatrics: A 10-year experience from a tertiary center in Brazil

ABSTRACT Introduction: Although still rare, pulmonary embolism (PE) in children has been increasing over the years. Data regarding this group of patients are still sparse, which contributes to the lack of standardized prophylaxis protocols and the misdiagnosis. This study aimed to determine the incidence of pediatric PE at a Brazilian tertiary hospital, describe clinical characteristics and identify possible risk factors. We also analyzed the diagnosis and management of PE. Methods: This was a retrospective review of tertiary Brazilian single-center data of all pediatric patients (0 - 18 years) with acute PE, diagnosed radiologically, from September 2009 to May 2019. Results: The incidence of PE was 3.3 cases per 10,000 hospitalized children. All the twenty-three cases had some risk factor identified and sixteen of them (69.5%) had more than one risk factor. The most important were central venous catheter (39.1%), malignancy (34.8%) and recent surgery (34.8%). Among the children with identifiable symptoms (69.5%), the most common was dyspnea (56.2%). Only one patient did not receive antithrombotic therapy because of the high bleeding risk and most patients (70.6%) were treated for 3 to 6 months. Among the nineteen patients alive at the end of the six-month follow-up, ten (52.6%) repeated the PE image control. Seven of them (70.0%) had complete or partial resolution of the thrombosis and none had worsening images. Conclusion: Our lower incidence than that of the current literature may reflect underdiagnosis due to low suspicion of PE. At least one risk factor was identified in all patients, which emphasizes the importance of increasing awareness of high-risk children.

Tromboembolismo pulmonar asociado a COVID-19 en paciente con síndrome de May-Thurner / COVID-19-associated Pulmonary Thromboembolism in a Patient with May-Thurner Syndrome

Introducción: El síndrome de May-Thurner es una enfermedad cuya prevalencia real es desconocida. Suele ser asintomática y las manifestaciones clínicas aparecen en el contexto de las complicaciones asociadas a la enfermedad. La aproximación diagnóstica se realiza por medio de imágenes, donde se identifican alteraciones patognomónicas que permiten descartar diagnósticos diferenciales. Se ha demostrado que la COVID-19 genera un estado protrombótico, que en contexto del síndrome de May-Thurner puede derivar en complicaciones tromboembólicas. Objetivo: Comparar la clínica y la posible relación de la enfermedad tromboembólica venosa en el curso de la COVID-19 en pacientes con SMT. Caso clínico: Mujer de 24 años, secretaria de profesión y residente en Bucaramanga. Presentó un cuadro clínico de 20 días de evolución que inició con rinorrea hialina, tos ocasional y mialgias; cinco días después manifestó fiebre no cuantificada y tos con expectoración hemoptoica. Conclusiones: Dentro de la fisiopatología de la infección por SARS-CoV-2 se desarrollan mecanismos procoagulantes, lo cual incrementa el riesgo de eventos trombóticos en pacientes con o sin factores de riesgo(AU)

Introduction: May-Thurner syndrome is a disease whose actual prevalence is unknown. It is usually asymptomatic and clinical manifestations appear in the context of complications associated with the disease. The diagnostic approach is performed by imaging, where pathognomonic alterations are identified to rule out differential diagnoses. It has been demonstrated that COVID-19 generates a prothrombotic state, which particularly in patients with May-Thurner syndrome would lead to thromboembolic complications. Objective: To compare the clinical and possible relationship of venous thromboembolic disease in the course of COVID-19 in patients with May-Thurner syndrome. Clinical case: 24-year-old woman, secretary by profession and resident in Bucaramanga, Colombia. She presented a clinical picture of 20 days of evolution that began with hyaline rhinorrhea, occasional cough and myalgias; five days later she manifested unquantified fever and cough with hemoptotic expectoration. Conclusions: Within the pathophysiology of SARS-CoV-2 infection, procoagulant mechanisms develop, which increases the risk of thrombotic events in patients with or without risk factors(AU)

Infarto pulmonar cavitado en mujer con lupus eritematoso sistémico asociado a síndrome antifosfolípido

Tanto lupus eritematoso sistémico como el síndrome antifosfolípido son enfermedades autoinmunes con potencial tromboembólico, sobre todo por la presencia de anticuerpos trombogénicos. El pulmón es un lugar común donde suele asentarse un trombo y generar una tromboembolia, a veces con posterior infarto y cavitación. Existen pocos estudios que informen un infarto pulmonar cavitado en un paciente con lupus asociado a síndrome antifosfolípido. Presentamos el caso de una mujer de 24 años con síntomas generales y lesión pulmonar derecha cavitada. Fue tratada inicialmente como infección tuberculosa o fúngica. La analítica y las imágenes orientaron y diagnosticaron lupus asociado a síndrome antifosfolípido, complicado con tromboembolismo pulmonar que luego pasó a cavitarse. La paciente mejoró considerablemente con anticoagulantes, corticoides y ciclofosfamida.

Both systemic lupus erythematosus and antiphospholipid syndrome are autoimmune diseases with thromboembolic potential, especially due to the presence of thrombogenic antibodies. The lung is a common place where a thrombus usually settles and generates a thromboembolism, sometimes with subsequent infarction and cavitation. There are few studies reporting cavitary pulmonary infarction in a patient with lupus associated with antiphospholipid syndrome. We present the case of a 24-year-old woman with general symptoms and cavitated right lung lesion. She was initially treated as tuberculous or fungal infection. Laboratory tests and images guided and diagnosed lupus associated with antiphospholipid syndrome, complicated by pulmonary thromboembolism that later became cavitated. The patient improved considerably with anticoagulants, corticosteroids, and cyclophosphamide.

Double Outlet Right Ventricle Infective Endocarditis: A Rare Combination and a Therapeutic Challenge

Infective endocarditis involving the right side of the heart occurs rarely and often involves the tricuspid valve. The isolated pulmonary valve infective endocarditis (IPVIE) is a less common condition that occurs in specific population. The double outlet right ventricle (DORV) is an unusual congenital heart disease. The association of DORV and IPVIE darkens the prognosis. We report two cases of the association of DORV and IPVIE. The transthoracic echocardiography (TTE) is the base to the diagnosis. Right sided infective endocarditis in the lack of a guided strategy remains a therapeutic challenge.

Cardiogenic shock due to pulmonary thromboembolism: the role of surgical thrombectomy / Shock cardiogénico debido a tromboembolismo pulmonar: el papel de trombectomía quirúrgica

Abstract A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Resumen Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

The Effect of Perioperative Fluid Management and Operative Modifications on Mortality and Morbidity in Patients Undergoing Pulmonary Endarterectomy

ABSTRACT Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease treated with pulmonary endarterectomy. Our study aims to reveal the differences in liquid modalities and operation modifications, which can affect the patients' mortality and morbidity. Methods: One hundred twenty-five patients who were diagnosed with CTEPH and underwent pulmonary thromboendarterectomy (PTE) at our center between February 2011 and September 2013 were included in this retrospective study with prospective observation. They were in New York Heart Association functional class II, III, or IV, and mean pulmonary artery pressure was > 40 mmHg. There were two groups, the crystalloid (Group 1) and colloid (Group 2) liquid groups, depending on the treatment fluids. P-value < 0.05 was considered statistically significant. Results: Although the two different fluid types did not show a significant difference in mortality between groups, fluid balance sheets significantly affected the intragroup mortality rate. Negative fluid balance significantly decreased mortality in Group 1 (P<0.01). There was no difference in mortality in positive or negative fluid balance in Group 2 (P>0.05). Mean duration of stay in the intensive care unit (ICU) for Group 1 was 6.2 days and for Group 2 was 5.4 days (P>0.05). Readmission rate to the ICU for respiratory or non-respiratory reasons was 8.3% (n=4) in Group 1 and 11.7% (n=9) in Group 2 (P>0.05). Conclusion: Changes in fluid management have an etiological significance on possible complications in patient follow-up. We believe that as new approaches are reported, the number of comorbid events will decrease.

Surgical Management of Massive Pulmonary Embolism Presenting with Cardiopulmonary Arrest: How Far Is Too Far?

ABSTRACT The incidence of diagnosed massive pulmonary embolism presenting to the Emergency Department is between 3% and 4.5% and it is associated with high mortality if not intervened timely. Cardiopulmonary arrest in this subset of patients carries a very poor prognosis, and various treating pathways have been applied with modest rate of success. Systemic thrombolysis is an established first line of treatment, but surgeons are often involved in the decision-making because of the improving surgical pulmonary embolectomy outcomes.

Presentations of pulmonary embolism in COVID-19: An Indian case series

The prevalence of pulmonary embolism (PE) among COVID-19 infections is significantly high. However, in resource-limited settings, appropriate computed tomography (CT) imaging is not possible for all COVID-19 patients. Very sick patients suspected of a PE may not be fit to be shifted to the CT room. Hence, it is likely that PE is underdiagnosed in Indian COVID-19 patients. Coexisting PE should be considered in all patients with influenza-like illnesses who have a Type 1 respiratory failure out of proportion to the severity of COVID-19 radiology. In this case series, we discuss the different presentations of PE in patients with COVID-19.

Tromboembolismo pulmonar de riesgo intermedio en el posoperatorio mediato de apendicectomía: informe de caso

Introducción: El tromboembolismo pulmonar es una enfermedad de relevancia clínica, en pacientes que se le han realizado intervenciones quirúrgicas. La tasa de mortalidad por esta causa ha disminuido en los últimos años. Objetivo: Describir el manejo diagnóstico y terapéutico del tromboembolismo pulmonar de riesgo intermedio. Caso clínico: Paciente masculino de 62 años de edad que se encontraba ingresado por haber sido operado de una apendicitis gangrenosa. En el posoperatorio mediato comenzó con cuadro de dificultad respiratoria, se realizaron exámenes complementarios incluido ecocardiograma transtorácico, donde se evidenció el signo de McConnell, por lo que se diagnosticó un tromboembolismo pulmonar de riesgo intermedio. El paciente se somete al tratamiento trombolítico estandarizado, luego de lo cual la clínica y los parámetros ecocardiográficos que evolucionaron hacia la mejoría. Conclusiones: Se describió el diagnóstico y tratamiento del tromboembolismo pulmonar de riesgo intermedio en el posoperatorio mediato de apendicectomía, donde se evidenció la utilidad del uso del ecocardiograma doppler transtorácico con la identificación de los signos característicos y la aplicación exitosa de trombolisis sistémica.

Introduction: Pulmonary thromboembolism (PTE) is an entity of clinical relevance in patients in settings related to surgical interventions. The mortality rate from this cause has decreased in recent years. Objective: To describe the diagnostic and therapeutic management of intermediate risk pulmonary thromboembolism. Clinical case: A 62-year-old male patient who was hospitalized for having been operated on for gangrenous appendicitis. In the immediate postoperative period, he begins with symptoms of respiratory distress, complementary tests are performed, including a transthoracic echocardiogram, where McConnell's sign is evident, for which an intermediate-risk pulmonary thromboembolism is diagnosed. The patient undergoes standardized thrombolytic treatment, after which the clinical and echocardiographic parameters evolve towards improvement. Conclusions: The diagnosis and treatment of intermediate risk pulmonary thromboembolism in the immediate postoperative period of appendectomy was described. The usefulness of the use of transthoracic Doppler echocardiography was evidenced with the identification of the characteristic signs and the successful application of systemic thrombolysis.

Pulmonary embolism in an adolescent with COVID-19 pneumonia / Tromboembolismo pulmonar en un adolescente con neumonía COVID-19

Abstract Background: Pulmonary embolism (PE) is a complication reported in the adult population with coronavirus disease 2019 (COVID-19); however, its documentation in the pediatric population is limiteda. Case report: We report the case of a 15-year-old male with obesity and Down syndrome who was admitted for severe COVID-19 pneumonia. On day 7 of admission, he presented with chest pain, hemoptysis, respiratory distress, and marked elevation of D-dimer. Pulmonary CT angiography found an extensive thrombus in the right lower lobar artery. He received treatment with enoxaparin and rivaroxaban and had a favorable clinical outcome. In the tomographic control 1 month after treatment, thrombus was not evidenced and was successfully resolved. Conclusions: There are few reports of PE in children with COVID-19. Prompt diagnosis and early anticoagulant treatment are important to avoid life-threatening complications.

Resumen Introducción: El tromboembolismo pulmonar es una complicación reportada en la población adulta con COVID-19; sin embargo, en la población pediátrica, su descripción es limitada. Caso clínico: Se reporta el caso de un varón de 15 años con antecedente de obesidad y síndrome de Down que fue hospitalizado por neumonía COVID-19 severa. En el séptimo día de hospitalización presentó dolor torácico, hemoptisis, dificultad respiratoria y elevación del dímero D. En la angiotomografía pulmonar se encontró un extenso trombo en la arteria lobar inferior derecha. Recibió tratamiento con enoxaparina y rivaroxabán evolucionando favorablemente. La resolución al mes de tratamiento fue existosa, ya que el control tomográfico no evidenció más el trombo. Conclusiones: El tromboembolismo pulmonar es una complicación poco reportada en niños con neumonía COVID-19. El diagnóstico oportuno y tratamiento anticoagulante es importante para evitar complicaciones mortales.

Effect of pulmonary embolism location on electrocardiological parameters

SUMMARY OBJECTIVE: Pulmonary thromboembolism is a disease with high morbidity and mortality. Various changes occur on the electrocardiogram secondary to pulmonary thromboembolism. The objective of this study was to investigate variations in QT dispersion, Tpeak-Tend duration, and Tpeak-Tend/QT ratio in relation to pulmonary thromboembolism localization and their impacts on 30-day mortality. METHODS: This study was carried out in a tertiary emergency medicine clinic between December 1, 2019 and November 30, 2020. We evaluated correlations between radiological outcomes of patients, QT dispersions, T-wave dispersions, Tpeak-Tend durations, and Tpeak-Tend/QT ratios. We sought statistically significant disparities between these values, considering the presence or localization of pulmonary thromboembolism. The 30-day mortality in pulmonary thromboembolism-diagnosed patients was reassessed. RESULTS: Electrocardiogramfindings revealed that T-wave dispersion (p<0.001), Tpeak-Tend duration (p=0.034), and Tpeak-Tend/corrected QT ratio (p=0.003) were lower in patients than controls. Conversely, QT dispersion (p=0.005) and corrected QT dispersion (p<0.001) were higher in patients. CONCLUSION: Electrocardiogram findings such as T-wave dispersion, QT duration, Tpeak-Tend time, and Tpeak-Tend/corrected QT ratio can detect pulmonary thromboembolism. More studies with larger cohorts are required to further understand the role of QT and corrected QT dispersion in pulmonary thromboembolism patient mortality.

Incidence and factors associated with pulmonary embolism among RT-PCR confirmed Covid-19 patients with upfront CT pulmonary angiography in Ethiopia: A nested case-control study

Introduction: Pulmonary embolism is one of the complications of COVID-19, with reported incidence ranging from 3 to 33 % in non-ICU patients to as high as 40% among ICU patients. Since the clinical presentations of COVID-19 and Pulmonary embolism overlap, it is difficult to differentiate between these cases. This study aimed to assess the incidence of pulmonary embolism and associated factors among confirmed Covid-19 Patients in Ethiopia. Methods: A nested case control study was conducted among 131 patients with COVID-19 (40 COVID-19 patients with Pulmonary embolism and 91 COVID-19 patients with no PE) who were on follow up from May, 2021 to May, 2022. Data was summarized using frequencies with percentages. A chi-square test/ Fisher's exact test was run to determine the presence of a significant difference between the exposure variables and the development of PE. To identify factors associated with the development of Pulmonary embolism, a multivariable Binary Logistic Regression model with sensitivity analysis was run. Results: The incidence of PE was 30.5% (95% CI, 22.9% - 37.4%) in the cohort of patients for whom upfront CTPA was performed. The Chi-square/ Fisher's exact test results showed a significantly higher proportion of patients with PE tend to present with shortness of breath, chest pain and anosmia/ageusia than those with no PE. However, in a subsequent regression analysis, only chest pain was found to be significantly associated with the development of PE in COVID-19 patients (AOR= 3.24, 95% CI= 1.10, 9.54, p-value=0.033). Conclusion: The incidence of PE among COVID-19 patients was found to be relatively lower than reports from other countries. Having chest pain was found to be a significant factor that indicates the development of PE, implying that in a setting where performing upfront CTPA is not practical, detailed symptom inquiry could serve as an important clinical criteria.

Application of low tube voltage and reduced contrast medium in CT pulmonary angiography / 中华放射医学与防护杂志

Objective:To explore the feasibility of 60 kV tube voltage combined with reduced contrast medium in CT pulmonary angiography (CTPA).Methods:Totally 60 outpatients and inpatients with a body mass index (BMI) of less than 25 kg/m 2 who had suspected pulmonary embolism and were arranged for CTPA examination were enrolled in this study. They were divided into a control group and an test group according to the random number table method. A protocol with a conventional dose was adopted in the control group. This scheme consisted of 100 kV tube voltage and injection of 50 ml of contrast medium at the rate of 4.5 ml/s. A scheme with a low dose was employed in the experimental group. Specifically, this scheme involved 60 kV tube voltage scheme and injection of 30 ml of contrast medium mixed with 20 ml of normal saline at a rate of 4.5 ml/s. The objective image quality was assessed by measuring the Hounsfield units (HU) of five regions of interest (ROIs), i. e., pulmonary trunk, right and left pulmonary arteries, and right and left lower lobar arteries, and the signal-to-noise ratio (SNR) and the contrast-to-noise ratio (CNR) were calculated. Moreover, the radiation doses were recorded. The subjective image quality was assessed by radiologists using a 5-point scale based on the overall image quality and the enhancement homogeneity of pulmonary arteries. The noise, SNR, CNR, and radiation dose of the two groups were compared using the Mann-Whitney U test, and the differences in the subjective image quality between the two groups were compared using the χ2 test. Results:All images met the requirements for clinical diagnosis. The two groups did not show significant differences in the overall subjective quality of CTPA images and enhancement scores ( P > 0.05), and in the average attenuation values of the pulmonary trunk and the left and right lower lobar arteries ( P > 0.05), but exhibited statistical differences in the average attenuation values of the left and right pulmonary arteries ( t = 2.75, 3.91, P < 0.05). There was no significant difference in the average background noise between the two groups ( P > 0.05). The test group had higher CNR of the left pulmonary artery and higher SNR and CNR of the right pulmonary artery than the control group, with statistically significant differences ( t = 0.04, 2.41, 3.08, P < 0.05). There was no significant difference in the SNR and CNR of other pulmonary artery branches between the two groups ( P > 0.05). The test group had an average effective dose of 1.24 mSv for CTPA, which was about one-third of that of the control group, with statistically significant differences ( t = 21.65, P < 0.05). Conclusions:The scheme of 60 kV tube voltage and reduced contrast medium for CTPA is feasible for patients with BMI < 25 kg/m 2. Using this scheme, the radiation and iodine dose can be reduced without affecting image quality.