Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli

Background: Acute pulmonary embolism (PE) is characterized hemodynamically by abrupt obstruction in trans-pulmonary blood flow. The echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation V<sub>max</sub>/mitral E/e’) has been validated as a non-invasive...

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Main Authors:	Isabel G. Scalia, William M. Scalia, Jonathon Hunter, Andrea Z. Riha, David Wong, Yael Celermajer, David G. Platts, Benjamin T. Fitzgerald, Gregory M. Scalia
Format:	Article
Language:	English
Published:	MDPI AG 2020-01-01
Series:	Journal of Clinical Medicine
Subjects:	pulmonary embolus echocardiography eplar
Online Access:	https://www.mdpi.com/2077-0383/9/1/247

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spelling	doaj-a205e1ea8e124c78a825d0949503f5a82020-11-25T02:33:37ZengMDPI AGJournal of Clinical Medicine2077-03832020-01-019124710.3390/jcm9010247jcm9010247Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary EmboliIsabel G. Scalia0William M. Scalia1Jonathon Hunter2Andrea Z. Riha3David Wong4Yael Celermajer5David G. Platts6Benjamin T. Fitzgerald7Gregory M. Scalia8Royal Brisbane and Women’s Hospital, Herston, QLD 4029, AustraliaThe Prince Charles Hospital, Brisbane, QLD 4032, AustraliaRedcliffe District Hospital, Redcliffe, QLD 4032, AustraliaThe Wesley Hospital, Brisbane, QLD 4066, AustraliaThe Wesley Hospital, Brisbane, QLD 4066, AustraliaRoyal Brisbane and Women’s Hospital, Herston, QLD 4029, AustraliaDepartment of Medicine, University of Queensland, Brisbane, QLD 4032, AustraliaThe Wesley Hospital, Brisbane, QLD 4066, AustraliaDepartment of Medicine, University of Queensland, Brisbane, QLD 4032, AustraliaBackground: Acute pulmonary embolism (PE) is characterized hemodynamically by abrupt obstruction in trans-pulmonary blood flow. The echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation V<sub>max</sub>/mitral E/e’) has been validated as a non-invasive surrogate for trans-pulmonary gradient (TPG) that accurately differentiates <i>pre-capillary</i> from <i>post-capillary</i> chronic pulmonary hypertension. This study assessed ePLAR as an incremental echocardiographic assessment tool compared with traditional measures of right ventricular pressure and function. Methods: In total, 110 (57.4 ± 17.6 years) patients with confirmed sub-massive pulmonary emboli with contemporaneous echocardiograms (0.3 ± 0.9 days) were compared with 110 age-matched controls (AMC). Results: Tricuspid velocities were higher than AMC (2.6 ± 0.6 m/s vs. 2.4 ± 0.3 m/s, <i>p</i> < 0.05), although still consistent with “normal” right ventricular systolic pressures (34.2 ± 13.5 mmHg vs. 25 ± 5.3 mmHg, <i>p</i> < 0.05) with lower mitral E/e’ values (8.2 ± 3.8 vs. 10.8 ± 5.1, <i>p</i> < 0.05). ePLAR values were higher than AMC (0.36 ± 0.14 m/s vs. 0.26 ± 0.10, <i>p</i> < 0.05) suggesting significantly elevated TPG. Detection of abnormal echocardiographic findings increased from 29% (TRV<sub>max</sub> ≥ 2.9 m/s) and 32% (reduced tricuspid annular plane systolic excursion) to 70% with ePLAR ≥ 0.3 m/s. Conclusions: Raised ePLAR values in acute sub-massive pulmonary embolism suggest elevated trans-pulmonary gradients even in the absence of acutely increased pulmonary artery pressures. ePLAR dramatically increases the sensitivity of echocardiography for detection of hemodynamic perturbations in sub-massive pulmonary embolism patients, which may offer clinical utility in diagnosis and management.https://www.mdpi.com/2077-0383/9/1/247pulmonary embolusechocardiographyeplar
collection	DOAJ
language	English
format	Article
sources	DOAJ
author	Isabel G. Scalia William M. Scalia Jonathon Hunter Andrea Z. Riha David Wong Yael Celermajer David G. Platts Benjamin T. Fitzgerald Gregory M. Scalia
spellingShingle	Isabel G. Scalia William M. Scalia Jonathon Hunter Andrea Z. Riha David Wong Yael Celermajer David G. Platts Benjamin T. Fitzgerald Gregory M. Scalia Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli Journal of Clinical Medicine pulmonary embolus echocardiography eplar
author_facet	Isabel G. Scalia William M. Scalia Jonathon Hunter Andrea Z. Riha David Wong Yael Celermajer David G. Platts Benjamin T. Fitzgerald Gregory M. Scalia
author_sort	Isabel G. Scalia
title	Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli
title_short	Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli
title_full	Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli
title_fullStr	Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli
title_full_unstemmed	Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli
title_sort	incremental value of eplar—the echocardiographic pulmonary to left atrial ratio in the assessment of sub-massive pulmonary emboli
publisher	MDPI AG
series	Journal of Clinical Medicine
issn	2077-0383
publishDate	2020-01-01
description	Background: Acute pulmonary embolism (PE) is characterized hemodynamically by abrupt obstruction in trans-pulmonary blood flow. The echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation V<sub>max</sub>/mitral E/e’) has been validated as a non-invasive surrogate for trans-pulmonary gradient (TPG) that accurately differentiates <i>pre-capillary</i> from <i>post-capillary</i> chronic pulmonary hypertension. This study assessed ePLAR as an incremental echocardiographic assessment tool compared with traditional measures of right ventricular pressure and function. Methods: In total, 110 (57.4 ± 17.6 years) patients with confirmed sub-massive pulmonary emboli with contemporaneous echocardiograms (0.3 ± 0.9 days) were compared with 110 age-matched controls (AMC). Results: Tricuspid velocities were higher than AMC (2.6 ± 0.6 m/s vs. 2.4 ± 0.3 m/s, <i>p</i> < 0.05), although still consistent with “normal” right ventricular systolic pressures (34.2 ± 13.5 mmHg vs. 25 ± 5.3 mmHg, <i>p</i> < 0.05) with lower mitral E/e’ values (8.2 ± 3.8 vs. 10.8 ± 5.1, <i>p</i> < 0.05). ePLAR values were higher than AMC (0.36 ± 0.14 m/s vs. 0.26 ± 0.10, <i>p</i> < 0.05) suggesting significantly elevated TPG. Detection of abnormal echocardiographic findings increased from 29% (TRV<sub>max</sub> ≥ 2.9 m/s) and 32% (reduced tricuspid annular plane systolic excursion) to 70% with ePLAR ≥ 0.3 m/s. Conclusions: Raised ePLAR values in acute sub-massive pulmonary embolism suggest elevated trans-pulmonary gradients even in the absence of acutely increased pulmonary artery pressures. ePLAR dramatically increases the sensitivity of echocardiography for detection of hemodynamic perturbations in sub-massive pulmonary embolism patients, which may offer clinical utility in diagnosis and management.
topic	pulmonary embolus echocardiography eplar
url	https://www.mdpi.com/2077-0383/9/1/247
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Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli

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