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- Essai clinique NCT03341208
Quantitative Assessment of RV Strain Using cMRI Following Catheter Intervention on PE (RVEF)
Quantitative Assessment of Right Ventricular Strain Utilizing Cardiac Magnetic Resonance Imaging: Development of an Optimal Measure of Treatment Response Following Catheter-directed Interventions on Sub-massive Pulmonary Embolism.
Acute pulmonary embolism (PE) is a condition in which the vessels carrying blood to the lungs become suddenly blocked, usually by a blood clot. There are a number of adverse consequences that result, with one of the most significant being strain on the right side of the heart (which must push blood through the blocked arteries to the lungs). Although this strain on the right heart is very important, current methods for measuring it are flawed. The standard practice is to obtain an echocardiogram (ultrasound of the heart), from which indirect measurements of the size of the heart are used to make inferences about right heart strain. This method can help guide management in some patients, but it in not a sensitive test and does not provide detailed information.
Patients with PE are treated with blood thinning medications. Some patients may be referred to the Interventional Radiology (IR) team for endovascular intervention, in which catheters are placed into the patient's vessels under radiologic guidance and advanced to the lungs to remove the clot entirely.
Cardiac magnetic resonance imaging (MRI) is a well-established imaging technique that produces highly detailed images of the heart's structure and function, with no risks to patients of ionizing radiation or intravenous contrast. Cardiac MRI is far superior to echocardiogram in evaluation of the right side of the heart, however it has not been widely used in the evaluation of patients with PE. We propose that by using a fast MRI protocol, we will be able to detect right heart strain with more accuracy than echocardiogram. Furthermore, we hypothesize that MRI images obtained before and after IR catheter-directed therapy will demonstrate the degree to which strain is relieved with this treatment. Finally, we believe that using MRI may help to guide management of patients with PE by detecting early or mild heart strain before it progresses.
In order to test these hypotheses, we plan to image PE patients who have been referred to the IR team with MRI. Patients recruited for this study will undergo two short MRI scans - one immediately before treatment, and one after completion of IR treatment (which lasts approximately 12-24 hours).
Aperçu de l'étude
Statut
Les conditions
Intervention / Traitement
Description détaillée
Pulmonary embolism occurs when embolic material (usually clot in the venous system) travels to the heart and lodges in the pulmonary vasculature. This obstruction, if significant, can lead to pulmonary arterial hypertension, which places increased demand on the right ventricle (RV), which must pump against the blockage. This can manifest as right ventricular dysfunction (RVD), which is characterized by dilatation of the RV, wall motion abnormalities and other structural and functional changes. There is a significant body of data demonstrating that function of the RV is an important prognostic indicator in patients with acute PE. In these studies, RVD allowed identification of patients who, although clinically stable on presentation, were at risk for hemodynamic instability and high morbidity/mortality. As a result, many authors have suggested that RVD represents an important indication for more aggressive therapy in patients with submassive PE.
Currently, echocardiography is the most commonly used method for evaluating the RV in acute PE. However, obtaining quality imaging of the RV using echocardiography is technically difficult, and determining a reliable indicator of RV function has proved challenging. A number of markers of right ventricular function have been described, including size criteria, ejection fraction, wall motion, tricuspid regurgitation, paradoxical septal motion, and others. However, there is no general consensus on which methodology or measurements produce the most clinically meaningful data. The American Heart Association guidelines for submassive pulmonary embolism use the ratio of the right ventricle to left ventricle at end diastole (RV:LV ratio), which is defined as greater than 0.9 in patients with RVD. However, there is a large degree of heterogeneity in echocardiographic criteria for RVD used in the literature.
Additionally, the quantitative data provided by echocardiography is suspect, as they show only modest correlation with cardiac magnetic resonance imaging (cMRI) or computed tomography (CT) in evaluation of the RV. Even when specifically utilizing the American Society of Echocardiography guidelines, echocardiography proves to be significantly less accurate than cMRI for evaluation of the RV, especially in patients with a dilated ventricle.
Cardiac magnetic resonance imaging is considered the reference standard for accurate evaluation of ventricular structure and function. It has proven its accuracy, reliability, and prognostic value in the setting of other pathologies that result in RV dysfunction, such as pulmonary hypertension. However, to date, this modality has not been used to provide detailed information about the structure and function of the RV in patients with acute PE.
Recently, new therapies for acute PE have come into use that allow more precise treatment of the embolus itself through the use of endovascular catheters. These catheter-directed therapies (CDTs) deliver thrombolytic medication or other treatment strategies directly to the pulmonary circulation. There is a strong body of evidence supporting the use of these therapies, and some devices have been FDA-approved for this indication. Despite this, there is a lack of definitive markers for the patients who would benefit most from this therapy. Additionally, techniques currently used to attempt to quantify response to therapy (such as RV:LV ratio) are not ideal. There remains a need for a quantitative method for evaluating the structure and function of the RV in patients with acute PE in order to determine their risk for hemodynamic compromise, the need for CDT, and response after therapy is completed.
Type d'étude
Inscription (Anticipé)
Contacts et emplacements
Coordonnées de l'étude
- Nom: Shannon Urbina, BS
- Numéro de téléphone: 520-626-7500
- E-mail: Shannon.Urbina@bannerhealth.com
Critères de participation
Critère d'éligibilité
Âges éligibles pour étudier
Accepte les volontaires sains
Sexes éligibles pour l'étude
Méthode d'échantillonnage
Population étudiée
La description
Inclusion Criteria:
- Participants will be patients who present to the emergency department or are inpatients in the hospital, who are found to have a diagnosis of acute pulmonary embolism (confirmed by computed tomography pulmonary angiography), and who have been referred to Interventional Radiology for evaluation for CDT. Patients appropriate for recruitment into this study will have large PEs involving lobar branches or more central segments of the pulmonary arteries.
Exclusion Criteria:
- Exclusion criteria will be limited to prisoners, pregnant women, patients for whom English or Spanish is not a first language, severe claustrophobia, and other routine contraindications for MRI. Patients with massive PE (resulting in hemodynamic instability) will not be appropriate participants for this study.
Plan d'étude
Comment l'étude est-elle conçue ?
Détails de conception
- Modèles d'observation: Cas uniquement
- Perspectives temporelles: Éventuel
Que mesure l'étude ?
Principaux critères de jugement
Mesure des résultats |
Description de la mesure |
Délai |
---|---|---|
Measure RVEF prior to and after catheter directed therapy to remove pulmonary thromboembolus
Délai: 2 years
|
Will predict severity of PE and identify patients that would most benefit from catheter therapy
|
2 years
|
Collaborateurs et enquêteurs
Parrainer
Les enquêteurs
- Chercheur principal: Charles Hennemeyer, MD, University of Arizona
Publications et liens utiles
Publications générales
- Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21. Erratum In: Circulation. 2012 Aug 14;126(7):e104. Circulation. 2012 Mar 20;125(11):e495.
- Kucher N, Boekstegers P, Muller OJ, Kupatt C, Beyer-Westendorf J, Heitzer T, Tebbe U, Horstkotte J, Muller R, Blessing E, Greif M, Lange P, Hoffmann RT, Werth S, Barmeyer A, Hartel D, Grunwald H, Empen K, Baumgartner I. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014 Jan 28;129(4):479-86. doi: 10.1161/CIRCULATIONAHA.113.005544. Epub 2013 Nov 13.
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- Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, Conti A, Agnelli G, Berni G. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000 Jun 20;101(24):2817-22. doi: 10.1161/01.cir.101.24.2817.
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- Cho JH, Kutti Sridharan G, Kim SH, Kaw R, Abburi T, Irfan A, Kocheril AG. Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis. BMC Cardiovasc Disord. 2014 May 6;14:64. doi: 10.1186/1471-2261-14-64.
- Jurcut R, Giusca S, La Gerche A, Vasile S, Ginghina C, Voigt JU. The echocardiographic assessment of the right ventricle: what to do in 2010? Eur J Echocardiogr. 2010 Mar;11(2):81-96. doi: 10.1093/ejechocard/jep234. Epub 2010 Feb 2.
- Wake N, Kumamaru KK, George E, Bedayat A, Ghosh N, Gonzalez Quesada C, Rybicki FJ, Gerhard-Herman M. Computed tomography and echocardiography in patients with acute pulmonary embolism: part 1: correlation of findings of right ventricular enlargement. J Thorac Imaging. 2014 Jan;29(1):W1-6. doi: 10.1097/RTI.0000000000000047.
- Pruszczyk P, Goliszek S, Lichodziejewska B, Kostrubiec M, Ciurzynski M, Kurnicka K, Dzikowska-Diduch O, Palczewski P, Wyzgal A. Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging. 2014 Jun;7(6):553-60. doi: 10.1016/j.jcmg.2013.11.004. Epub 2014 Jan 8.
- Kjaergaard J, Petersen CL, Kjaer A, Schaadt BK, Oh JK, Hassager C. Evaluation of right ventricular volume and function by 2D and 3D echocardiography compared to MRI. Eur J Echocardiogr. 2006 Dec;7(6):430-8. doi: 10.1016/j.euje.2005.10.009. Epub 2005 Dec 9.
- Lai WW, Gauvreau K, Rivera ES, Saleeb S, Powell AJ, Geva T. Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography. Int J Cardiovasc Imaging. 2008 Oct;24(7):691-8. doi: 10.1007/s10554-008-9314-4. Epub 2008 Apr 28.
- Mooij CF, de Wit CJ, Graham DA, Powell AJ, Geva T. Reproducibility of MRI measurements of right ventricular size and function in patients with normal and dilated ventricles. J Magn Reson Imaging. 2008 Jul;28(1):67-73. doi: 10.1002/jmri.21407.
- van Wolferen SA, Marcus JT, Boonstra A, Marques KM, Bronzwaer JG, Spreeuwenberg MD, Postmus PE, Vonk-Noordegraaf A. Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension. Eur Heart J. 2007 May;28(10):1250-7. doi: 10.1093/eurheartj/ehl477. Epub 2007 Jan 22.
- Benza R, Biederman R, Murali S, Gupta H. Role of cardiac magnetic resonance imaging in the management of patients with pulmonary arterial hypertension. J Am Coll Cardiol. 2008 Nov 18;52(21):1683-92. doi: 10.1016/j.jacc.2008.08.033.
- Alunni JP, Degano B, Arnaud C, Tetu L, Blot-Souletie N, Didier A, Otal P, Rousseau H, Chabbert V. Cardiac MRI in pulmonary artery hypertension: correlations between morphological and functional parameters and invasive measurements. Eur Radiol. 2010 May;20(5):1149-59. doi: 10.1007/s00330-009-1664-3. Epub 2010 Jan 22.
- Sista AK, Kearon C. Catheter-Directed Thrombolysis for Pulmonary Embolism: Where Do We Stand? JACC Cardiovasc Interv. 2015 Aug 24;8(10):1393-1395. doi: 10.1016/j.jcin.2015.06.009. No abstract available.
- Piazza G, Hohlfelder B, Jaff MR, Ouriel K, Engelhardt TC, Sterling KM, Jones NJ, Gurley JC, Bhatheja R, Kennedy RJ, Goswami N, Natarajan K, Rundback J, Sadiq IR, Liu SK, Bhalla N, Raja ML, Weinstock BS, Cynamon J, Elmasri FF, Garcia MJ, Kumar M, Ayerdi J, Soukas P, Kuo W, Liu PY, Goldhaber SZ; SEATTLE II Investigators. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015 Aug 24;8(10):1382-1392. doi: 10.1016/j.jcin.2015.04.020.
Dates d'enregistrement des études
Dates principales de l'étude
Début de l'étude (Anticipé)
Achèvement primaire (Anticipé)
Achèvement de l'étude (Anticipé)
Dates d'inscription aux études
Première soumission
Première soumission répondant aux critères de contrôle qualité
Première publication (Réel)
Mises à jour des dossiers d'étude
Dernière mise à jour publiée (Réel)
Dernière mise à jour soumise répondant aux critères de contrôle qualité
Dernière vérification
Plus d'information
Termes liés à cette étude
Termes MeSH pertinents supplémentaires
Autres numéros d'identification d'étude
- UArizonaIR
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