Prognostic role of right atrial and ventricular strain in patients with acute pulmonary embolism
Authors: Fabiani G , Pellegrino A , Pelagatti L , Galli I , Innocenti F , Nazerian P , Modesti P A , Vanni S 
Published: January 2025

Abstract

Background
Acute pulmonary embolism (PE) is a common and potentially fatal condition, with mortality rates varying based on clinical severity. While patients with hemodynamic instability face the highest short-term mortality risk, the majority of patients are hemodynamically stable and identifying normotensive patients who may benefit from aggressive management remains controversial. Right ventricular dysfunction (RVD) is a known prognostic marker in PE but it is not standardized. Moreover, several indexes are currently used to identify RVD but which index or group of indexes are the best predictors is not well defined.

Purpose
Our aim was to investigate the prognostic role of new indexes of ventricular function, ventricular and atrial strain, in patients with PE.

Methods
Consecutive hemodynamically stable patients diagnosed with acute PE were included in the present pilot study. The diagnosis of PE was confirmed by pulmonary CT angiography (CTPA). RVD was defined as the presence of at least one of the following: TAPSE &lt; 16 mm, right ventricular diameter &gt; 35 mm, paradoxical systolic movement of the septum. Global longitudinal (GLS) and circumferential strain (GCS) calculations of the right atrium atrium and right ventricle were performed offline using 2D speckle-tracking analysis. The primary outcome was the combination of death due to PE or haemodynamic instability/complicated course during hospitalisation. Complicated course was defined based on the presence of at least one of the following: SBP &lt;90mmHg for at least 15 minutes, the need for catecholamine administration, the need for thrombolytic therapy, the need for mechanical ventilation or the need for cardiopulmonary resuscitation, death from PE. Comparison of echocardiographic parameters between patients who achieved or did not achieve the primary outcome was performed using ANOVA.

Results
We included 27 patients (mean age 80 years, female 40,7%), of whom 8 (29,6%) developed the primary outcome. No patient died from PE during hospitalization. Considering traditional methods of assessing right ventricular function, patients who achieved the primary outcome showed lower TAPSE values (14,0 ± 3,7 mm vs 20,3 ± 4,9 mm, p=0,010) and a larger right ventricle, considering the mean endsystolic diameter (ESDmid) (37,8 ± 14,7 vs 26,5 ± 8,6 mm, p=0,019). GCS and GLS of the right ventricle were not significantly different between the two groups, while the time to peak free-wall (ttpFW) difference between the two groups (409,8 ± 139,8 vs 277,2 ± 92,3) was significant. Similarly, right atrium GCS was significantly reduced in patients who achieved the primary outcome compared to those who remained hemodynamically stable (12,9 ± 4,8 vs 21,5 ± 10,6 respectively, p=0,042).

Conclusions
Right atrial global circumferential strain appears to identify normotensive patients with pulmonary embolism who will develop a complicated course better than RV strain parameters.