Lung Ventilation/Perfusion Scintigraphy for the Screening of Chronic Thromboembolic Pulmonary Hypertension (CTEPH): Which Criteria to Use?

Objective: The diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) is a major challenge as it is a curable cause of pulmonary hypertension (PH). Ventilation/Perfusion (V/Q) lung scintigraphy is the imaging modality of choice for the screening of CTEPH. However, there is no consensus on the criteria to use for interpretation. The aim of this study was to assess the accuracy of various interpretation criteria of planar V/Q scintigraphy for the screening of CTEPH in patients with PH. Methods: The eligible study population consisted of consecutive patients with newly diagnosed PH in the Brest University Hospital, France. Final diagnosis (CTEPH or non-CTEPH) was established in a referential center on the management of PH, based on the ESC/ERS guidelines and a minimum follow-up of 3 years. A retrospective central review of planar V/Q scintigraphy was performed by three nuclear physicians blinded to clinical findings and to final diagnosis. The number, extent (sub-segmental or segmental) and type (matched or mismatched) of perfusion defects were reported. Sensitivity and specificity were evaluated for various criteria based on the number of mismatched perfusion defects and the number of perfusion defects (regardless of ventilation). Receiver operating characteristic (ROC) curves were generated and areas under the curve (AUC) were calculated for both. Results: A total of 226 patients with newly diagnosed PH were analyzed. Fifty six (24.8%) were diagnosed with CTEPH while 170 patients (75.2%) were diagnosed with non-CTEPH. The optimal threshold was 2.5 segmental mismatched perfusion defects, providing a sensitivity of 100 % (95% CI 93.6-100%) and a specificity of 94.7% (95%CI 90.3-97.2%). Lower diagnostic cut-offs of mismatched perfusion defects provided similar sensitivity but lower specificity. Ninety five percent of patients with CTEPH had more than 4 segmental mismatched defects. An interpretation only based on perfusion provided similar sensitivity but a specificity of 81.8% (95%CI 75.3-86.9%). Conclusion: Our study confirmed the high diagnostic performance of planar V/Q scintigraphy for the screening of CTEPH in patients with PH. The optimal diagnostic cut-off for interpretation was 2.5 segmental mismatched perfusion defects. An interpretation only based on perfusion defects provided similar sensitivity but lower specificity.

Risk factors for recurrence during a pregnancy following a first venous thromboembolism: A French observational study.

BACKGROUND: Women with a previous venous thromboembolism (VTE) are at risk of recurrence during pregnancy. OBJECTIVES: We aimed to assess the incidence rate of recurrent VTE during pregnancy, according to the period of pregnancy, and the clinical parameters associated with recurrence, in a prospective cohort of women of childbearing age after a first VTE. PATIENTS/METHODS: A total of 189 women aged 15-49 years with a first documented VTE were followed until a subsequent pregnancy of at least 20 weeks' gestation between 2000 and 2020. VTE recurrences during pregnancy were recorded, as were potential clinical risk factors for recurrence. RESULTS: Recurrent VTE occurred in six women during antepartum: five during the first trimester (incidence rate 106.4 per 1000 women-years) (95% confidence interval [CI] 46.3-226.0); none during the second trimester; and one during the third trimester (incidence rate 27.0 per 1000 women-years [95% CI 4.8-138.2]). During postpartum, recurrences occurred in 11 women (incidence rate 212.8 per 1000 women-years [95% CI 119.9-349.1]). These 17 recurrent VTEs presented as pulmonary embolism ± deep vein thrombosis (DVT) in five patients and isolated DVT in 12. Failure of thromboprophylaxis occurred in two cases (33.3%) antepartum and in 10 cases (90.9%) postpartum. In multivariable analysis, only obesity (defined on prepregnancy body mass index) was associated with recurrent VTE (odds ratio 3.34 [95% CI 1.11-10.05, p = .03]). CONCLUSIONS: This study confirms a high risk of recurrent VTE postpartum, despite thromboprophylaxis, in women with a previous VTE. Only obesity was associated with VTE recurrence during pregnancy, suggesting that low-dose anticoagulation might not be appropriate in obese pregnant women.

Evaluation of the predictive value of the bleeding prediction score VTE-BLEED for recurrent venous thromboembolism.

INTRODUCTION: VTE-BLEED is a validated score for identification of patients at increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE). It is unknown whether VTE-BLEED high-risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score. METHODS: This was a post hoc analysis of the randomized, double-blind, placebo-controlled PADIS-PE trial that randomized patients with a first unprovoked pulmonary embolism (PE) initially treated during 6 months to receive an additional 18-month of warfarin vs. placebo. The primary outcome of this analysis was recurrent VTE during 2-year follow-up after anticoagulant discontinuation, that is, after the initial 6-month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted for study treatment allocation, was compared between patients in the high- vs. low-risk VTE-BLEED group. RESULTS: In complete case analysis (n = 308; 82.4% of total population), 89 (28.9%) patients were classified as high risk; 44 VTE events occurred after anticoagulant discontinuation during 668 patient-years. The cumulative incidence of recurrent VTE was 16.4% (95% confidence interval [CI], 10.0%-26.1%; 14 events) and 14.6% (95% CI, 10.4%-20.3%; 30 events) in the high-risk and low-risk VTE-BLEED groups, respectively, for an adjusted hazard ratio of 1.16 (95% CI, 0.62-2.19). CONCLUSION: In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE-BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.

Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience.

STUDY OBJECTIVE: To evaluate patient and surgical characteristics of laparoscopic hysterectomy (LH), including both total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LSH), compared with total abdominal hysterectomy (TAH). DESIGN: Retrospective, comparative study (Canadian Task Force classification II-2). SETTING: Health maintenance organization/residency-training program. PATIENTS: One hundred eight patients who underwent TLH, 251 patients who underwent LSH, and 255 patients who underwent TAH. There was no randomized controlled system to assign patients to the three types of hysterectomy. Patients with ancillary procedures were excluded from all three groups. The study period included February 2000 through September 2002. INTERVENTION: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Analysis of covariance revealed that laparoscopic procedures require significantly more time to complete than TAH. Adjusted differences were 46.4 minutes longer for TLH (p <.0001) and 38.3 minutes longer for LSH (p <.0001). The adjusted estimated blood loss was 91.0 mL less with TLH (p <.0001) and 72.6 mL less with LSH (p < .0001) than with TAH. The hospital lengths of stay were significantly shorter for LH compared with TAH. The adjusted differences were 41.7 hours less with TLH (p <.0001) and 45.1 hours less with LSH (p <.0001). Rates of major complications were 5.6% with TLH, 0.8% with LSH, and 8.2% with TAH. Rates of minor complications were 17.6% with TLH, 16.7% with LSH, and 14.1% with TAH. Rates of any complication were 21.3% with TLH, 17.1% with LSH, and 20.8% with TAH. (Note: some patients in each group had both a minor and a major complication, so that minor and major complications do not exactly add up to "any complication.") The readmission rates for TLH, LSH, and TAH were 5.6%, 1.2%, and 2.0%, respectively. Same-day discharge for TLH and LSH occurred in 16.7% and 25.1% of patients, respectively. The variables indicating minor complications, any complications, wound infections, urinary tract infections, readmissions, and same-day discharges (in the laparoscopic groups) were not differentiated by surgery type. Major complications were differentiated by procedure class; namely, total hysterectomy (TLH and TAH) had significantly more major complications than LSH (adjusted p = .001). Wound abscesses (16 patients) occurred only in the TAH group (adjusted p <.0001). Pelvic cellulitis (17 patients) occurred in all surgical groups, but was more likely to occur in the LH groups (adjusted p = .01). CONCLUSIONS: Laparoscopic hysterectomy, both total and supracervical, can be successfully integrated into a large health maintenance organization/residency-training program. Laparoscopic hysterectomy took significantly longer to perform than TAH in this new program. Estimated blood loss was significantly less with LH than with TAH. Hospital length of stay was significantly less with LH than TAH. Major complications with TLH, minor complications with LH, overall complications, wound infections, urinary tract infections, and readmissions appear comparable with these parameters in TAH within the limits of our study size and design. Pelvic cellulitis was significantly more common with LH, and wound abscess was significantly more common with TAH. Major complications were significantly less common with LSH compared with combined TLH and TAH. Same-day discharge after LH seems to be an attractive option worth developing further. Our patients have enthusiastically accepted these new minimally invasive techniques for performing hysterectomy. We anticipate continued expansion of our LH program.

Retained fragments after total laparoscopic hysterectomy.

A 36-year-old woman had a history of worsening menorrhagia, refractory to medical therapy. She underwent a total laparoscopic hysterectomy. Postoperatively, she experienced significant dyspareunia, dysuria, and pelvic pain. Ten months after her initial procedure, laparoscopy revealed several parasitized fragments of uterine and cervical origin in the pelvis. As laparoscopic morcellation is performed with increased frequency, the need to understand its sequelae has also increased. A concern of morcellating tissue within the abdomen is the fate of fragments inadvertently left behind.