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Increase in Size of RV/LV Ratio More Accurate for Predicting PE Mortality

January 19, 2008
Written by: , Filed in: Cardiac Imaging
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The objective of a recent study was to evaluate if the interim increase in size of right ventricular-left ventricular (RV/LV) diameter ratio of the heart is more accurate than the RV/LV diameter ratio itself in predicting 30-day mortality from acute pulmonary embolism (PE).
The study has concluded that the interim increase in size of the RV/LV diameter ratio of the heart on CT pulmonary angiography is more accurate than the RV/LV diameter ratio itself in predicting 30-day mortality for acute pulmonary embolism.

Participants
50 patients who had a positive CT PE study and a prior negative CT PE study. Median interval between examinations was 63 days (range, 3 to 840 days).

Methodology
ECG gating was not used. For each CT, a reformatted 4-chamber view was made on a separate workstation. The 4-chamber view is a plane along a line that bisects the center of the mitral valve and cardiac apex on a sagittal reformatted image.
On the 4-chamber view, diameters of ventricles were measured as the distance between the interventricular septum and the endocardial border perpendicular to the long axis of the heart.
The interim increase in size of the RV/LV diameter ratio of the heart was the percentage change in RV/LV diameter ratio between prior negative CT PE study and current positive CT PE study.

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Results
12 patients (24%) died in the 30-day follow-up period; 9 (18%) due to acute PE, 1 from sepsis, and 2 from malignancy.
The interim increase in size of the RV/LV diameter ratio between the negative CT PE study and the positive CT PE study was more accurate than the RV/LV diameter ratio of the positive CT PE study itself (area under the ROC curve [AUC], 0.95 vs 0.73; P =0.003) for predicting PE-related mortality and for predicting all-cause mortality (AUC, 0.81 vs 0.66; P =0.05).
For an interim increase in RV/LV diameter ratio >18%, the respective sensitivity, specificity, positive-predictive value, and negative-predictive value were 0.78 (95% CI, 0.43, 1.00), 0.93 (95% CI, 0.83, 1.00), 0.70 (95% CI, 0.38, 1.00), and 0.95 (95% CI, 0.87, 1.00) for PE-related mortality.
At a target sensitivity of 0.75, the specificity of interim increase in size of the RV/LV diameter ratio was higher than the RV/LV diameter ratio of the positive CT PE study itself (0.93 vs 0.59; P =0.001) for PE-related mortality.

Conclusions
For PE-related mortality, an interim increase in RV/LV ratio >18% was significantly more specific and had a significantly higher positive-predictive value than did an RV/LV diameter ratio of >1.0 of the positive CT PE study alone. The same was true for all-cause mortality using an interim increase in RV/LV diameter ratio >15%.

Reviewer’s Comments
The Author: s have demonstrated that the interim increase in size of the RV/LV ratio is more accurate than the RV/LV diameter ratio itself for predicting PE-related mortality. Constructing a 4-chamber view, however, in each CT PE study may be somewhat cumbersome.

Author: : Vineet R. Jain, MD

Reference: :
Lu MT, Cai T, et al. Interval Increase in Right-Left Ventricular Diameter Ratios at CT as a Predictor of 30-Day Mortality After Acute Pulmonary Embolism: Initial Experience.
Radiology; 2008; 246 (January): 281-287

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