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Pulmonary Embolism

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The Right Heart

Abstract

Acute pulmonary embolism (aPE) is one of the great masqueraders in medicine. Therefore, a high index of clinical suspicion coupled with a detailed history and physical examination is invaluable when evaluating patients. Acute venous thromboembolism (VTE) that usually originates from the lower extremity deep veins (DVT) is clearly recognized as a significant healthcare problem. In the United States an estimated 900,000 cases of DVT and PE occur per year, causing approximately 300,000 deaths. Clinically, aPE is defined as massive, sub-massive, or non-massive. In the assessment and management of patients presenting with suspected aPE, clinical information is critical not only to the initial assessment of prognosis, but also to guide therapeutic decision-making. Hemodynamic stability and right ventricular (RV) function are found to be critically important in determining morbidity and mortality. Thus, risk stratification algorithms have been proposed to help physicians identify high- versus low-risk aPE patients in order to expedite diagnosis and treatment. Computed tomographic pulmonary angiography (CTPA) has been the imaging of choice in aPE patients not only for its higher sensitivity and specificity, but also for providing alternate diagnosis in patients with nonspecific signs and symptoms of aPE. More recently, echocardiography has been able to provide anatomical, functional, as well as mechanical information regarding RV function and RV-pulmonary unit interaction. This chapter intents to not only summarize the most important pathophysiological processes involved from clot formation to distal pulmonary embolization, but also describe potential hemodynamic implications and associated clinical manifestations. Current diagnostic and therapeutic algorithms are reviewed; available imaging modalities with most typically diagnostic aPE features are described; and mechanical characterization of the anatomical and functional abnormalities with regard to RV function are examined in terms of the hemodynamic derangement caused by acute obstruction to pulmonary flow.

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Abbreviations

aPE:

Acute pulmonary embolism

AUC:

Appropriate use criteria

BP:

Blood pressure

BNP:

Brain natriuretic peptide

CDMT:

Catheter-directed mechanical thrombectomy

CTEPH:

Chronic thromboembolic pulmonary hypertension

CTPA:

Computed tomographic pulmonary angiography

DVT:

Deep venous thrombosis

DOACs:

Direct-acting oral anticoagulants

ECG:

Electrocardiogram

ESLD:

End-stage liver disease

ESC:

European Society of Cardiology

FAC:

Fractional area change

IVS:

Interventricular septum

LV:

Left ventricle

LMWH:

Low-molecular-weight heparin

OR:

Odds ratio

PIOPED:

Prospective investigation of pulmonary embolism diagnosis

PA:

Pulmonary artery

PERC:

Pulmonary Embolism Rule-out Criteria

PH:

Pulmonary hypertension

PVR:

Pulmonary vascular resistance

RHS:

Right-heart strain

RV:

Right ventricle

RVOT:

RV outflow tract

TTE:

Transthoracic echocardiogram

TAPSE:

Tricuspid annular plane systolic excursion

TR:

Tricuspid regurgitation

UFH:

Unfractionated heparin

VTI:

Velocity time integral

VTE:

Venous thromboembolism

V/Q scan:

Ventilation-perfusion scintigraphy

VKA:

Vitamin K antagonist

References

  1. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(Suppl. 3):338–400S.

    Article  Google Scholar 

  2. Den Heijer M, Rosendaal FR, Blom HJ, Gerrits WB, Bos GM. Hyperhomocysteinemia and venous thrombosis: a meta-analysis. Thromb Haemost. 1998;80:566–9.

    Article  Google Scholar 

  3. Martinelli I, Mannucci PM, De Stefano V, Taioli E, Rossi V, Crosti F, Paciaroni K, Leone G, Faioni EM. Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families. Blood. 1998;92:2353–8.

    Article  CAS  PubMed  Google Scholar 

  4. Heit JA, Silverstein MD, Mohr DN, Petterson TM, Lohse CM, O’Fallon WM, Melton LJ 3rd. The epidemiology of venous thromboembolism in the community. Thromb Haemost. 2001;86:452–63.

    Article  CAS  PubMed  Google Scholar 

  5. Galli M, Luckiani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood. 2003;101:1827–32.

    Article  CAS  PubMed  Google Scholar 

  6. White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost. 2003;90:446–55.

    Article  CAS  PubMed  Google Scholar 

  7. Alikhan R, Cohen RT, Combe S, Samama MM, Desjardins L, Eldor A, Janbon C, Leizorovicz A, Olsson CG, Turpie AG. Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study. Arch Intern Med. 2004;164:963–8.

    Article  PubMed  Google Scholar 

  8. Hoffman M, Monroe DM. Coagulation 2006: a modern view of hemostasis. Hematol Oncol Clin North Am. 2007;21(1):1–11. https://doi.org/10.1016/j.hoc.2006.11.004.

    Article  PubMed  Google Scholar 

  9. Cina G, Marra R, Di Stasi C, Macis G. Epidemiology, pathophysiology and natural history of venous thromboembolism. Rays. 1996;21:315–27.

    CAS  PubMed  Google Scholar 

  10. Wilkins RW, Stanton JR. Elastic stockings in the prevention of pulmonary embolism: a progress report. N Engl J Med. 1953;248:1087–90.

    Article  CAS  PubMed  Google Scholar 

  11. Ramzi DW, Leeper KV. DVT and pulmonary embolism: part II. Treatment and prevention. Am Fam Physician. 2004;69:2841–8.

    PubMed  Google Scholar 

  12. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I22–30.

    PubMed  Google Scholar 

  13. Heit JA, Cohen AT, Anderson FJ. Estimated annual number of incident and recurrent, non-fatal venous thromboembolism (VTE) events in the US. Blood. 2005;106:11.

    Article  Google Scholar 

  14. Boulay F, Berthier F, Schoukroun G, et al. Seasonal variations in hospital admission for deep vein thrombosis and pulmonary embolism: analysis of discharge data. BMJ. 2001;323:601–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Cervantes J, Rojas G. Virchows legacy: deep vein thrombosis and pulmonary embolism. World J Surg. 2005;29:S30–4.

    Article  PubMed  Google Scholar 

  16. Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrom J. Incidence and mortality of venous thrombosis: a population based study. J Thromb Haemost. 2007;5:692–9.

    Article  CAS  PubMed  Google Scholar 

  17. Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P, Folsom AR. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004;117:19–25.

    Article  PubMed  Google Scholar 

  18. Rosendaal FR, Reitsma PH. Genetics of venous thrombosis. J Thromb Haemost. 2009;7(suppl 1):301–4.

    Article  CAS  PubMed  Google Scholar 

  19. Wakefield TW, Myers DD, Henke PK. Mechanisms of venous thrombosis and resolution. Arterioscler Thromb Vasc Biol. 2008;28:387–91.

    Article  CAS  PubMed  Google Scholar 

  20. Becker BF, Heindl B, Kupatt C, Zahler S. Endothelial function and hemostasis. Z Kardiol. 2000;89:160–7.

    CAS  PubMed  Google Scholar 

  21. Gross PL, Aird WC. The endothelium and thrombosis. Semin Thromb Hemost. 2000;26:463–78.

    Article  CAS  PubMed  Google Scholar 

  22. Mackman N. New insights into the mechanisms of venous thrombosis. J Clin Invest. 2012;122:2331–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Mackman N. Triggers, targets and treatments for thrombosis. Nature. 2008;451:914–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med. 2008;359:938–49.

    Article  CAS  PubMed  Google Scholar 

  25. Lippi G, Franchini M, Targher G. Arterial thrombus formation in cardiovascular disease. Nat Rev Cardiol. 2011;8:502–12.

    Article  PubMed  Google Scholar 

  26. Jackson SP. Arterial thrombosis-insidious, unpredictable and deadly. Nat Med. 2011;17:1423–36.

    Article  CAS  PubMed  Google Scholar 

  27. Undas A, Ariëns RA. Fibrin clot structure and function: a role in the pathophysiology of arterial and venous thromboembolic diseases. Arterioscler Thromb Vasc Biol. 2011;31:e88–99.

    Article  CAS  PubMed  Google Scholar 

  28. Wolberg AS. Plasma and cellular contributions to fibrin network formation, structure, and stability. Haemophilia. 2010;16(Suppl 3):7–12.

    Article  CAS  PubMed  Google Scholar 

  29. Mackman N. Role of tissue factor in hemostasis, thrombosis, and vascular development. Arterioscler Thromb Vasc Biol. 2004;24:1015–22.

    Article  CAS  PubMed  Google Scholar 

  30. Hoffbrand AV, Pettit JE. Essential hematology. 3rd ed. Oxford: Blackwell Scientific Publications; 1993.

    Google Scholar 

  31. Virchow RLK. Gesammelte Abhandlungen zur wissenschaftlichen Medicin. Von Meidinger & Sohn: Frankfurt; 1856.

    Google Scholar 

  32. Iorio A, et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med. 2010;170:1710–6.

    Article  PubMed  Google Scholar 

  33. Rosendaal FR, van Hylckama VA, Doggen CJ. Venous thrombosis in the elderly. J Thromb Haemost. 2007;5(suppl 1):310–7.

    Article  PubMed  Google Scholar 

  34. Lowe GD, et al. Epidemiology of coagulation factors, inhibitors and activation markers: the Third Glasgow MONICA Survey. I. Illustrative reference ranges by age, sex and hormone use. Br J Haematol. 1997;97:775–84.

    Article  CAS  PubMed  Google Scholar 

  35. Li C, Ford ES, McGuire LC, Mokdad AH. Increasing trends in waist circumference and abdominal obesity among US adults. Obesity (Silver Spring). 2007;15:216–24.

    Article  Google Scholar 

  36. Smeeth L, Cook C, Thomas S, Hall AJ, Hubbard R, Vallance P. Risk of deep vein thrombosis and pulmonary embolism after acute infection in a community setting. Lancet. 2006;367:1075–9.

    Article  PubMed  Google Scholar 

  37. Osterud B, Due J Jr. Blood coagulation in patients with benign and malignant tumours before and after surgery. Special reference to thromboplastin generation in monocytes. Scand J Haematol. 1984;32:258–64.

    Article  CAS  PubMed  Google Scholar 

  38. Johnson GJ, Leis LA, Bach RR. Tissue factor activity of blood mononuclear cells is increased after total knee arthroplasty. Thromb Haemost. 2009;102:728–34.

    Article  CAS  PubMed  Google Scholar 

  39. White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med. 1998;158:1525–31.

    Article  CAS  PubMed  Google Scholar 

  40. James AH. Venous thromboembolism in pregnancy. Arterioscler Thromb Vasc Biol. 2009;29:326–31.

    Article  CAS  PubMed  Google Scholar 

  41. Bremme KA. Haemostatic changes in pregnancy. Best Pract Res Clin Haematol. 2003;16:153–68.

    Article  PubMed  Google Scholar 

  42. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006;194:1311–5.

    Article  PubMed  Google Scholar 

  43. Middeldorp S, et al. Effects on coagulation of levonorgestrel- and desogestrel-containing low dose oral contraceptives: a cross-over study. Thromb Haemost. 2000;84:4–8.

    Article  CAS  PubMed  Google Scholar 

  44. Vandenbroucke JP, et al. Oral contraceptives and the risk of venous thrombosis. N Engl J Med. 2001;344:1527–35.

    Article  CAS  PubMed  Google Scholar 

  45. Abdollahi M, Cushman M, Rosendaal FR. Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost. 2003;89:493–8.

    Article  CAS  PubMed  Google Scholar 

  46. Ayer JG, Song C, Steinbeck K, Celermajer DS, Ben Freedman S. Increased tissue factor activity in monocytes from obese young adults. Clin Exp Pharmacol Physiol. 2010;37:1049–54.

    Article  CAS  PubMed  Google Scholar 

  47. Khorana AA. Venous thromboembolism and prognosis in cancer. Thromb Res. 2010;125:490–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia. 2002;4:465–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Allman-Farinelli MA. Obesity and venous thrombosis: a review. Semin Thromb Hemost. 2011;37:903–7.

    Article  PubMed  Google Scholar 

  50. Noble S, Pasi J. Epidemiology and pathophysiology of cancer-associated thrombosis. Br J Cancer. 2010;102:S2–9.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Verbeek TA, Jonathan SG, Saner FH, et al. Hypercoagulability in end-stage liver disease: review of epidemiology, etiology, and management. Transplant Direct. 2018;4(11):e403. https://doi.org/10.1097/TXD.0000000000000843.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158:585–93.

    Article  CAS  PubMed  Google Scholar 

  53. Northup PG, McMahon MM, Ruhl AP, et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101:1524–8.

    Article  PubMed  Google Scholar 

  54. Heit JA, Silverstein MD, Mohr DN, et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160:809–15.

    Article  CAS  PubMed  Google Scholar 

  55. Huerta C, Johansson S, Wallander MA, et al. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med. 2007;167:935–43.

    Article  PubMed  Google Scholar 

  56. Gulley D, Teal E, Suvannasankha A, et al. Deep vein thrombosis and pulmonary embolism in cirrhosis patients. Dig Dis Sci. 2008;53:3012–7.

    Article  PubMed  Google Scholar 

  57. Wu H, Nguyen GC. Liver cirrhosis is associated with venous thromboembolism among hospitalized patients in a nationwide US study. Clin Gastroenterol Hepatol. 2010;8:800–5.

    Article  PubMed  Google Scholar 

  58. Northup PG, Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol. 2013;11:1064–74.

    Article  PubMed  Google Scholar 

  59. Dabbagh O, Oza A, Prakash S, et al. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;137:1145–9.

    Article  PubMed  Google Scholar 

  60. Cockett FB, Thomas ML. The iliac compression syndrome. Br J Surg. 1965;52:816–21.

    Article  CAS  PubMed  Google Scholar 

  61. Moudgill N, Hager E, Gonsalves C, Larson R, Lombardi J, DiMuzio P. May-Thurner syndrome: case report and review of the literature involving modern endovascular therapy. Vascular. 2009;17:330–5.

    Article  PubMed  Google Scholar 

  62. Bovill EG, van der Vliet A. Venous valvular stasis-associated hypoxia and thrombosis: what is the link? Annu Rev Physiol. 2011;73:527–45.

    Article  CAS  PubMed  Google Scholar 

  63. Nicolaides AN, Kakkar VV, Field ES, et al. The origin of deep vein thrombosis: a venographic study. Br J Radiol. 1971;44:653–63.

    Article  CAS  PubMed  Google Scholar 

  64. Kakkar VV, Howe CT, Flanc C, et al. Natural history of postoperative deep-vein thrombosis. Lancet. 1969;2:230–2.

    Article  CAS  PubMed  Google Scholar 

  65. Cogo A, Lensing AWA, Prandoni P, et al. Distribution of thrombosis in patients with symptomatic deep-vein thrombosis: implications for simplifying the diagnostic process with compression ultrasound. Arch Intern Med. 1993;153:2777–80.

    Article  CAS  PubMed  Google Scholar 

  66. Moser KM, LeMoine JR. Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med. 1981;94:439–44.

    Article  CAS  PubMed  Google Scholar 

  67. Malone PC, Agutter PS. The aetiology of deep venous thrombosis. QJM. 2006;99:581–93.

    Article  CAS  PubMed  Google Scholar 

  68. Hamer JD, Malone PC, Silver IA. The PO2 in venous valve pockets: its possible bearing on thrombogenesis. Br J Surg. 1981;68(3):166–70.

    Article  CAS  PubMed  Google Scholar 

  69. Liu GC, Ferris EJ, Reifsteck JR, Baker ME. Effect of anatomic variations on deep venous thrombosis of the lower extremity. Am J Roentgenol. 1986;146(4):845–8.

    Article  CAS  Google Scholar 

  70. Varma MR, Varga AJ, Knipp BS, Sukheepod P, Upchurch GR, Kunkel SL, Wakefield TW, Henke PK. Neutropenia impairs venous thrombosis resolution in the rat. J Vasc Surg. 2003;38:1090–8.

    Article  PubMed  Google Scholar 

  71. Stewart GJ. Neutrophils and deep venous thrombosis. Haemostasis. 1993;23(Suppl 1):127–40.

    PubMed  Google Scholar 

  72. Henke PK, Pearce CG, Moaveni DM, Moore AJ, Lynch EM, Longo C, Varma M, Dewyer NA, Deatrick KB, Upchurch GR Jr, Wakefield TW, Hogaboam C, Kunkel SL. Targeted deletion of CCR2 impairs deep vein thrombosis resolution in a mouse model. J Immunol. 2006;177:3388–97.

    Article  CAS  PubMed  Google Scholar 

  73. Henke PK, Varma MR, Moaveni DK, Dewyer NA, Moore AJ, Lynch EM, Longo C, Deatrick CB, Kunkel SL, Upchurch GR Jr, Wakefield TW. Fibrotic injury after experimental deep vein thrombosis is determined by the mechanism of thrombogenesis. Thromb Haemost. 2007;98:1045–55.

    Article  CAS  PubMed  Google Scholar 

  74. Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol. 2015;12(8):464–74. https://doi.org/10.1038/nrcardio.2015.83.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Barsoum MK, Heit JA, Ashrani AA, Leibson CL, Petterson TM, Bailey KR. Is progestin an independent risk factor for incident venous thromboembolism? A population-based case-control study. Thromb Res. 2010;126(5):373–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Merrer J, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286:700–7.

    Article  CAS  PubMed  Google Scholar 

  77. Cogo A, et al. Acquired risk factors for deep-vein thrombosis in symptomatic outpatients. Arch Intern Med. 1994;154:164–8.

    Article  CAS  PubMed  Google Scholar 

  78. Kuipers S, et al. The absolute risk of venous thrombosis after air travel: a cohort study of 8,755 employees of international organisations. PLoS Med. 2007;4:e290.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Doggen CJ, et al. Serum lipid levels and the risk of venous thrombosis. Arterioscler Thromb Vasc Biol. 2004;24:1970–5.

    Article  CAS  PubMed  Google Scholar 

  80. Decousus H, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med. 2010;152:218–24.

    Article  PubMed  Google Scholar 

  81. Noboa S, Mottier D, Oger E, EPI-GETBO Study Group. Estimation of a potentially preventable fraction of venous thromboembolism: a community-based prospective study. J Thromb Haemost. 2006;4(12):2720–2.

    Article  CAS  PubMed  Google Scholar 

  82. Chew HK, Wun T, Harvey D, Zhou H, White RH. Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med. 2006;166:458–64.

    Article  PubMed  Google Scholar 

  83. Blom JW, et al. Incidence of venous thrombosis in a large cohort of 66,329 cancer patients: results of a record linkage study. J Thromb Haemost. 2006;4:529–35.

    Article  CAS  PubMed  Google Scholar 

  84. Heit JA, et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160:809–15.

    Article  CAS  PubMed  Google Scholar 

  85. Khorana AA, Kuderer NM, Culakova E, Lyman GH, Francis CW. Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood. 2008;111:4902–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  86. Ay C, et al. Prediction of venous thromboembolism in cancer patients. Blood. 2010;116:5377–82.

    Article  CAS  PubMed  Google Scholar 

  87. Huang W, Goldberg RJ, Anderson FA, Kiefe CI, Spencer FA. Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE study (1985–2009). Am J Med. 2014;127:829.e5–39.e5.

    Article  Google Scholar 

  88. Heit JA. Estimating the incidence of symptomatic postoperative venous thromboembolism: the importance of perspective. JAMA. 2012;307:306–7.

    Article  CAS  PubMed  Google Scholar 

  89. Spencer FA, et al. Incidence rates, clinical profile, and outcomes of patients with venous thromboembolism. The Worcester VTE study. J Thromb Thrombolysis. 2009;28:401–9.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Heit JA, et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med. 2000;160:761–8.

    Article  CAS  PubMed  Google Scholar 

  91. van Dongen CJ, Vink R, Hutten BA, Büller HR, Prins MH. The incidence of recurrent venous thromboembolism after treatment with vitamin K antagonists in relation to time since first event: a meta-analysis. Arch Intern Med. 2003;163:1285–93.

    Article  PubMed  Google Scholar 

  92. Schulman S, et al. Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006;4:734–42.

    Article  CAS  PubMed  Google Scholar 

  93. Prandoni P, et al. Residual venous thrombosis as a predictive factor of recurrent venous thromboembolism. Ann Intern Med. 2002;137:955–60.

    Article  PubMed  Google Scholar 

  94. Kyrle PA, Eichinger S. The risk of recurrent venous thromboembolism: the Austrian Study on Recurrent Venous Thromboembolism. Wien Klin Wochenschr. 2003;115:471–4.

    Article  PubMed  Google Scholar 

  95. Baglin T, et al. Does the clinical presentation and extent of venous thrombosis predict likelihood and type of recurrence? A patient-level meta-analysis. J Thromb Haemost. 2010;8:2436–42.

    Article  CAS  PubMed  Google Scholar 

  96. Kovacs MJ, et al. Patients with a first symptomatic unprovoked deep vein thrombosis are at higher risk of recurrent venous thromboembolism than patients with a first unprovoked pulmonary embolism. J Thromb Haemost. 2010;8:1926–32.

    Article  CAS  PubMed  Google Scholar 

  97. Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group. Am J Med. 1998;104:332–8.

    Article  CAS  PubMed  Google Scholar 

  98. Garcia D, Akl EA, Carr R, Kearon C. Antiphospholipid antibodies and the risk of recurrence after a first episode of venous thromboembolism: a systematic review. Blood. 2013;122:817–24.

    Article  CAS  PubMed  Google Scholar 

  99. Jayakody Arachchillage D, Greaves M. The chequered history of the antiphospholipid syndrome. Br J Haematol. 2014;165:609–17.

    Article  PubMed  Google Scholar 

  100. Brouwer JL, et al. High long-term absolute risk of recurrent venous thromboembolism in patients with hereditary deficiencies of protein S, protein C or antithrombin. Thromb Haemost. 2009;101:93–9.

    Article  CAS  PubMed  Google Scholar 

  101. Chee CE, et al. Predictors of venous thromboembolism recurrence and bleeding among active cancer patients: a population-based cohort study. Blood. 2014;123:3972–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med. 2000;343:1758–64.

    Article  CAS  PubMed  Google Scholar 

  103. Buckingham M, Meilhac S, Zaffran S. Building the mammalian heart from two sources of myocardial cells. Nat Rev Genet. 2005;6:826–35.

    Article  CAS  PubMed  Google Scholar 

  104. Bruneau BG. The developmental genetics of congenital heart disease. Nature. 2008;451:943–8.

    Article  CAS  PubMed  Google Scholar 

  105. Larsen WJ. Human embryology. New York: Churchill Livingstone; 1993. p. 111–204.

    Google Scholar 

  106. Moore KL, Persaud TV. The developing human: clinically oriented embryology. Philadelphia, PA: WB Saunders; 1998. p. 241–53, 329–80.

    Google Scholar 

  107. Murillo H, Cutalo MJ, Jones RP, Lane MJ, Fleischmann D, Restrepo CS. Pulmonary circulation imaging: embryology and normal anatomy. Semin Ultrasound CT MR. 2012;33:473–84.

    Article  PubMed  Google Scholar 

  108. Gao Y, Raj JU. Regulation of the pulmonary circulation in the fetus and newborn. Physiol Rev. 2010;90:1291–335.

    Article  CAS  PubMed  Google Scholar 

  109. Burri PH. Structural aspects of postnatal lung development—alveolar formation and growth. Biol Neonate. 2006;89:313–22.

    Article  PubMed  Google Scholar 

  110. Sylvester JT, Shimoda LA, Aaronson PI, Ward JP. Hypoxic pulmonary vasoconstriction. Physiol Rev. 2012;92:367–520.

    Article  CAS  PubMed  Google Scholar 

  111. Berrocal T, Madrid C, Novo S, et al. Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology. Radiographics. 2003;24:e17.

    Article  PubMed  Google Scholar 

  112. Castañer E, Gallardo X, Rimola J, et al. Congenital and acquired pulmonary artery anomalies in the adult: radiologic overview. Radiographics. 2006;26:349–71.

    Article  PubMed  Google Scholar 

  113. Grosse C, Grosse A. CT findings in diseases associated with pulmonary hypertension: a current review. Radiographics. 2010;30:1753–77.

    Article  PubMed  Google Scholar 

  114. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, et al. Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol. 2001;37:183–8.

    Article  CAS  PubMed  Google Scholar 

  115. Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost. 2008;100:747–51.

    Article  CAS  PubMed  Google Scholar 

  116. Sanchez O, Trinquart L, Colombet I, et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J. 2008;29:1569–77.

    Article  PubMed  Google Scholar 

  117. Stevinson BG, Hernandez-Nino J, Rose G, Kline JA. Echocardiographic and functional cardiopulmonary problems six months after first-time pulmonary embolism in previously healthy patients. Eur Heart J. 2007;28:2517–24.

    Article  PubMed  Google Scholar 

  118. Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation. 2008;117:1436–48.

    Article  PubMed  Google Scholar 

  119. Voelkel NF, Quaife RA, Leinwand LA, Barst RJ, McGoon MD, Meldrum DR, et al. Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure. Circulation. 2006;114:1883–91.

    Article  PubMed  Google Scholar 

  120. Hemnes AR, Champion HC. Right heart function and haemodynamics in pulmonary hypertension. Int J Clin Pract. 2008;62(Suppl 160):11–9.

    Article  Google Scholar 

  121. McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation. 2009;119:2250–94.

    Article  PubMed  Google Scholar 

  122. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386–9.

    Article  CAS  PubMed  Google Scholar 

  123. Stein PD, Matta F, Alrifai A, Rahman A. Trends in case fatality rate in pulmonary embolism according to stability and treatment. Thromb Res. 2012;130(6):841–6.

    Article  CAS  PubMed  Google Scholar 

  124. Watts JA, Marchick MR, Kline JA. Right ventricular heart failure from pulmonary embolism: key distinctions from chronic pulmonary hypertension. J Card Fail. 2010;16:250–9.

    Article  PubMed  Google Scholar 

  125. Bristow MR, Zisman LS, Lowes BD, Abraham WT, Badesch DB, Groves BM, Voelkel NF, Lynch DM, Quaife RA. The pressure-overloaded right ventricle in pulmonary hypertension. Chest. 1998;114(1 Suppl):101S–6S.

    Article  CAS  PubMed  Google Scholar 

  126. Carabello BA. The relationship of left ventricular geometry and hypertrophy to left ventricular function in valvular heart disease. J Heart Valve Dis. 1995;4(Suppl 2):S132–8.

    PubMed  Google Scholar 

  127. Konstam MA, Cohen SR, Salem DN, et al. Comparison of left and right ventricular end-systolic pressure-volume relations in congestive heart failure. J Am Coll Cardiol. 1985;5:1326–34.

    Article  CAS  PubMed  Google Scholar 

  128. Nakamura H, Adachi H, Sudoh A, Yagyu H, Kishi K, Oh-ishi S, et al. Subacute cor pulmonale due to tumor embolism. Intern Med. 2004;43:420–2.

    Article  PubMed  Google Scholar 

  129. Archer S, Michelakis E. The mechanism(s) of hypoxic pulmonary vasoconstriction: potassium channels, redox O(2) sensors, and controversies. News Physiol Sci. 2002;17:131–7.

    CAS  PubMed  Google Scholar 

  130. Memtsoudis SG, Rosenberger P, Walz JM. Critical care issues in the patient after major joint replacement. J Intens Care Med. 2007;22:92–104.

    Article  Google Scholar 

  131. Toledo LS, Mauad R. Complications of body sculpture: prevention and treatment. Clin Plastic Surg. 2006;33:1–11.

    Article  Google Scholar 

  132. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106:164–77.

    Article  PubMed  Google Scholar 

  133. Smulders YM. Pathophysiology and treatment of haemodynamic instability in acute pulmonary embolism: the pivotal role of pulmonary vasoconstriction. Cardiovasc Res. 2000;48:23–33.

    Article  CAS  PubMed  Google Scholar 

  134. Jones AE, Watts JA, Debelak JP, Thornton LR, Younger JG, Kline JA. Inhibition of prostaglandin synthesis during polystyrene microsphere-induced pulmonary embolism in the rat. Am J Physiol Lung Cell Mol Physiol. 2003;284:L1072–81.

    Article  CAS  PubMed  Google Scholar 

  135. Reeves WC, Demers LM, Wood MA, Skarlatos S, Copenhaver G, Whitesell L, et al. The release of thromboxane A2 and prostacyclin following experimental acute pulmonary embolism. Prostagland Leukotrienes Med. 1983;11:1–10.

    Article  CAS  Google Scholar 

  136. Todd MH, Forrest JB, Cragg DB. The effects of aspirin and methysergide, singly and in combination, on systemic haemodynamic responses to pulmonary embolism. Can Anaesth Soc J. 1981;28:373–80.

    Article  CAS  PubMed  Google Scholar 

  137. Breuer J, Meschig R, Breuer HW, Arnold G. Effects of serotonin on the cardiopulmonary circulatory system with and without 5-HT2-receptor blockade by ketanserin. J Cardiovasc Pharmac. 1985;7:64–6.

    Article  Google Scholar 

  138. Battistini B. Modulation and roles of the endothelins in the pathophysiology of pulmonary embolism. Can J Physiol Pharmacol. 2003;81:555–69.

    Article  CAS  PubMed  Google Scholar 

  139. Kapsch DN, Metzler M, Silver D. Contributions of prostaglandin F2 alpha and thromboxane A2 to the acute cardiopulmonary changes of pulmonary embolism. J Surg Res. 1981;30:522–9.

    Article  CAS  PubMed  Google Scholar 

  140. Kim SH, Yi MZ, Kim DH, Song JM, Kang DH, Lee SD, Song JK. Prognostic value of echocardiographic estimation of pulmonary vascular resistance in patients with acute pulmonary thromboembolism. J Am Soc Echocardiogr. 2011;24:693–8.

    Article  PubMed  Google Scholar 

  141. Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ, ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41:2245–51.

    Article  PubMed  Google Scholar 

  142. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014;35(43):3033–80.

    Article  CAS  PubMed  Google Scholar 

  143. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol. 1971;28(3):288–94.

    Article  CAS  PubMed  Google Scholar 

  144. Delcroix M, Mélot C, Lejeune P, Leeman M, Naeije R. Effects of vasodilators on gas exchange in acute canine embolic pulmonary hypertension. Anesthesiology. 1990;72(1):77–84.

    Article  CAS  PubMed  Google Scholar 

  145. Lankhaar JW, Westerhof N, Faes TJ, Marques KM, Marcus JT, Postmus PE, Vonk-Noordegraaf A. Quantification of right ventricular afterload in patients with and without pulmonary hypertension. Am J Physiol Heart Circ Physiol. 2006;291(4):H1731–7.

    Article  CAS  PubMed  Google Scholar 

  146. Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost. 2010;8(7):1509–14.

    Article  CAS  PubMed  Google Scholar 

  147. Donzé J, Le Gal G, Fine MJ, et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost. 2008;100(5):943–8.

    Article  PubMed  CAS  Google Scholar 

  148. Vanni S, Nazerian P, Pepe G, et al. Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach. J Thromb Haemost. 2011;9(10):1916–23.

    Article  CAS  PubMed  Google Scholar 

  149. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041–6.

    Article  PubMed  PubMed Central  Google Scholar 

  150. Jimenez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383–9.

    Article  PubMed  Google Scholar 

  151. Righini M, Roy PM, Meyer G, et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost. 2011;9(10):2115–7.

    Article  CAS  PubMed  Google Scholar 

  152. Nassiri N, Jain A, McPhee D, Mina B, Rosen RJ, Giangola G, et al. Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy. Ann Vasc Surg. 2012;26(1):18–24.

    Article  PubMed  Google Scholar 

  153. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158:585–93.

    Article  CAS  PubMed  Google Scholar 

  154. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363:266–74.

    Article  CAS  PubMed  Google Scholar 

  155. Piazza G, Goldhaber SZ. Current concepts: chronic thromboembolic pulmonary hypertension. New Engl J Med. 2011;364:351–60.

    Article  CAS  PubMed  Google Scholar 

  156. Jiménez D, de Miguel-Díez J, Guijarro R, et al., RIETE Investigators. Trends in the management and outcomes of acute pulmonary embolism: analysis from the RIETE Registry. J Am Coll Cardiol. 2016;67(2):162–70.

    Google Scholar 

  157. Hsiao SH, Lee CY, Chang SM, Yang SH, Lin SK, Huang WC. Pulmonary embolism and right heart function: insights from myocardial Doppler tissue imaging. J Am Soc Echocard. 2006;19:822–8.

    Article  Google Scholar 

  158. Iwadate K, Tanno K, Doi M, Takatori T, Ito Y. Two cases of right ventricular ischemic injury due to massive pulmonary embolism. Forensic Sci Int. 2001;116:189–95.

    Article  CAS  PubMed  Google Scholar 

  159. Begieneman MP, van de Goot FR, van der Bilt I, Noordegraaf AV, Spreeuwenberg MD, Paulus WJ, et al. Pulmonary embolism causes endomyocarditis in the human heart. Heart. 2008;94:450–6.

    Article  CAS  PubMed  Google Scholar 

  160. Zagorski J, Gellar MA, Obraztsova M, Kline JA, Watts JA. Inhibition of CINC-1 decreases right ventricular damage caused by experimental pulmonary embolism in rats. J Immunol. 2007;179:7820–6.

    Article  CAS  PubMed  Google Scholar 

  161. Watts JA, Zagorski J, Gellar MA, Stevinson BG, Kline JA. Cardiac inflammation contributes to right ventricular dysfunction following experimental pulmonary embolism in rats. J Molec Cell Cardiol. 2006;41:296–307.

    Article  CAS  Google Scholar 

  162. Kline JA, Zeitouni R, Marchick MR, Hernandez-Nino J, Rose GA. Comparison of 8 biomarkers for prediction of right ventricular hypokinesis 6 months after submassive pulmonary embolism. Am Heart J. 2008;156:308–14.

    Article  CAS  PubMed  Google Scholar 

  163. Nordenholz KE, Mitchell AM, Kline JA. Direct comparison of the diagnostic accuracy of fifty protein biological markers of pulmonary embolism for use in the emergency department. Acad Emerg Med. 2008;15:795–9.

    Article  PubMed  Google Scholar 

  164. Mitchell AM, Nordenholz KE, Kline JA. Tandem measurement of D dimer and myeloperoxidase of C-reactive protein to effectively screen for pulmonary embolism in the emergency department. Acad Emerg Med. 2008;15:800–5.

    Article  PubMed  Google Scholar 

  165. Torrent-Guasp F, Whimster WF, Redmann K. A silicone rubber mould of the heart. Technol Health Care. 1997;5:13–20.

    Article  CAS  PubMed  Google Scholar 

  166. Buckberg GD, RESTORE Group. The ventricular septum: the lion of right ventricular function, and its impact on right ventricular restoration. Eur J Cardiothorac Surg. 2006;29(Suppl 1):S272–8.

    Article  PubMed  Google Scholar 

  167. Sallin EA. Fiber orientation and ejection fraction in the human left ventricle. Biophys J. 1969;9:954–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  168. Damiano RJ Jr, La Follette P Jr, Cox JL, Lowe JE, Santamore WP. Significant left ventricular contribution to right ventricular systolic function. Am J Physiol. 1991;261(5 Pt 2):H1514–24.

    PubMed  Google Scholar 

  169. Osculati G, Malfatto G, Chianca R, Perego GB. Left-to-right systolic ventricular interaction in patients undergoing biventricular stimulation for dilated cardiomyopathy. J Appl Physiol. 2010;109:418–23.

    Article  PubMed  Google Scholar 

  170. Schwarz K, Singh S, Dawson D, Frenneaux MP. Right ventricular function in left ventricular disease: pathophysiology and implications. Heart Lung Circ. 2013;22:507–11.

    Article  PubMed  Google Scholar 

  171. Mori S, Nakatani S, Kanzaki H, Yamagata K, Take Y, Matsuura Y, et al. Patterns of the interventricular septal motion can predict conditions of patients with pulmonary hypertension. J Am Soc Echocardiogr. 2008;21:386–93.

    Article  PubMed  Google Scholar 

  172. Ramani GV, Bazaz R, Edelman K, López-Candales A. Pulmonary hypertension affects left ventricular basal twist: a novel use for speckle-tracking imaging. Echocardiography. 2009;26:44–51.

    Article  PubMed  Google Scholar 

  173. López-Candales A, Edelman K. Chronic pulmonary hypertension causes significant interventricular spatiotemporal dyssynchrony when onset of diastolic flow signals are assessed by color M-mode. Echocardiography. 2012;29:653–60.

    Article  PubMed  Google Scholar 

  174. Piazza G. Submassive pulmonary embolism. JAMA. 2013;309(2):171–80.

    Article  CAS  PubMed  Google Scholar 

  175. Konstantinides S. Should thrombolytic therapy be used in patients with pulmonary embolism? Am J Cardiovasc Drugs. 2004;4:69–74.

    Article  PubMed  Google Scholar 

  176. Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997;30:1165–71.

    Article  CAS  PubMed  Google Scholar 

  177. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121:877–905.

    Article  PubMed  Google Scholar 

  178. Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomized trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993;314:507–11.

    Article  Google Scholar 

  179. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al. Short-term clinical outcome of patients with pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817–22.

    Article  CAS  PubMed  Google Scholar 

  180. Frémont B, Pacouret G, Jacobi D, Puglisi R, Charbonnier B, de Labriolle A. Prognostic value of echocardiographic right/left ventricular end-diastolic diameter ratio in patients with acute pulmonary embolism: results from a monocenter registry of 1,416 patients. Chest. 2008;133:358–62.

    Article  PubMed  Google Scholar 

  181. Sanchez O, Trinquart L, Caille V, Couturaud F, Pacouret G, Meneveau N, et al. Prognostic factors for pulmonary embolism: the PREP Study, a prospective multicenter cohort study. Am J Respir Crit Care Med. 2010;181:168–73.

    Article  CAS  PubMed  Google Scholar 

  182. Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med. 2005;165:1777–81.

    Article  PubMed  Google Scholar 

  183. Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995;108:978–81.

    Article  CAS  PubMed  Google Scholar 

  184. Miniati M, Pistolesi M, Marini C, et al. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med. 1996;154(5):1387–93.

    Article  CAS  PubMed  Google Scholar 

  185. Musset D, Parent F, Meyer G, et al. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet. 2002;360(9349):1914–20.

    Article  PubMed  Google Scholar 

  186. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165–71.

    Article  PubMed  Google Scholar 

  187. PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990;263(20):2753–9.

    Article  Google Scholar 

  188. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: in- creasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416–20.

    Article  CAS  PubMed  Google Scholar 

  189. Anderson DR, Kovacs MJ, Dennie C, et al. Use of spiral computed tomography contrast angiography and ultrasonography to exclude the diagnosis of pulmonary embolism in the emergency department. J Emerg Med. 2005;29(4):399–404.

    Article  PubMed  Google Scholar 

  190. Kearon C, Ginsberg JS, Douketis J, et al. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med. 2006;144(11):812–21.

    Article  PubMed  Google Scholar 

  191. Sohne M, Kamphuisen PW, van Mierlo PJ, et al. Diagnostic strategy using a modified clinical decision rule and D-dimer test to rule out pulmonary embolism in elderly in- and outpatients. Thromb Haemost. 2005;94(1):206–10.

    PubMed  Google Scholar 

  192. van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172–9.

    Article  PubMed  Google Scholar 

  193. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98–107.

    Article  CAS  PubMed  Google Scholar 

  194. Rodger MA, Maser E, Stiell I, et al. The interobserver reliability of pretest probability assessment in patients with suspected pulmonary embolism. Thromb Res. 2005;116(2):101–7.

    Article  CAS  PubMed  Google Scholar 

  195. Runyon MS, Webb WB, Jones AE, et al. Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule: a prospective observational study. Acad Emerg Med. 2005;12(7):587–93.

    Article  PubMed  Google Scholar 

  196. Ghaye B, Szapiro D, Mastora I, et al. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis? Radiology. 2001;219(3):629–36.

    Article  CAS  PubMed  Google Scholar 

  197. Patel S, Kazerooni EA, Cascade PN. Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT. Radiology. 2003;227(2):455–60.

    Article  PubMed  Google Scholar 

  198. Remy-Jardin M, Remy J, Wattinne L, et al. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique: comparison with pulmonary angiography. Radiology. 1992;185(2):381–7.

    Article  CAS  PubMed  Google Scholar 

  199. Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317–27.

    Article  CAS  PubMed  Google Scholar 

  200. Carrier M, Righini M, Wells PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8(8):1716–22.

    Article  CAS  PubMed  Google Scholar 

  201. Stein PD, Goodman LR, Hull RD, et al. Diagnosis and management of isolated subsegmental pulmonary embolism: review and assessment of the options. Clin Appl Thromb Hemost. 2012;18(1):20–6.

    Article  PubMed  Google Scholar 

  202. Goodman LR, Stein PD, Matta F, et al. CT venography and compression sonography are diagnostically equivalent: data from PIOPED II. AJR Am J Roentgenol. 2007;189(5):1071–6.

    Article  PubMed  Google Scholar 

  203. Farrell C, Jones M, Girvin F, et al. Unsuspected pulmonary embolism identified using multidetector computed tomography in hospital outpatients. Clin Radiol. 2010;65(1):1–5.

    Article  CAS  PubMed  Google Scholar 

  204. Jia CF, Li YX, Yang ZQ, et al. Prospective evaluation of unsuspected pulmonary embolism on coronary computed tomographic angiography. J Comput Assist Tomogr. 2012;36(2):187–90.

    Article  PubMed  Google Scholar 

  205. Palla A, Rossi G, Falaschi F, et al. Is incidentally detected pulmonary embolism in cancer patients less severe? A case-control study. Cancer Invest. 2012;30(2):131–4.

    Article  CAS  PubMed  Google Scholar 

  206. Sahut D’Izarn M, Caumont Prim A, Planquette B, et al. Risk factors and clinical outcome of unsuspected pulmonary embolism in cancer patients: a case-control study. J Thromb Haemost. 2012;10(10):2032–8.

    Article  PubMed  Google Scholar 

  207. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S–94S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  208. Alderson PO. Scintigraphic evaluation of pulmonary embolism. Eur J Nucl Med. 1987;13(Suppl):S6–10.

    PubMed  Google Scholar 

  209. Bajc M, Neilly JB, Miniati M, Schuemichen C, Meignan M, Jonson B, EANM Committee. EANM guidelines for ventilation/perfusion scintigraphy: part 1. Pulmonary imaging with ventilation/perfusion single photon emission tomography. Eur J Nucl Med Mol Imaging. 2009;36(8):1356–70.

    Article  CAS  PubMed  Google Scholar 

  210. Bajc M, Neilly JB, Miniati M, Schuemichen C, Meignan M, Jonson B. EANM guidelines for ventilation/perfusion scintigraphy: part 2. Algorithms and clinical considerations for diagnosis of pulmonary emboli with V/P(SPECT) and MDCT. Eur J Nucl Med Mol Imaging. 2009;36(9):1528–38.

    Article  CAS  PubMed  Google Scholar 

  211. Reid JH, Coche EE, Inoue T, et al. Is the lung scan alive and well? Facts and controversies in defining the role of lung scintigraphy for the diagnosis of pulmonary embolism in the era of MDCT. Eur J Nucl Med Mol Imaging. 2009;36(3):505–21.

    Article  PubMed  Google Scholar 

  212. Gottschalk A, Sostman HD, Coleman RE, et al. Ventilation-perfusion scintigraphy in the PIOPED study. Part II. Evaluation of the scintigraphic criteria and interpretations. J Nucl Med. 1993;34(7):1119–26.

    CAS  PubMed  Google Scholar 

  213. Sostman HD, Coleman RE, DeLong DM, et al. Evaluation of revised criteria for ventilation-perfusion scintigraphy in patients with suspected pulmonary embolism. Radiology. 1994;193(1):103–7.

    Article  CAS  PubMed  Google Scholar 

  214. Bajc M, Olsson B, Palmer J, et al. Ventilation/perfusion SPECT for diagnostics of pulmonary embolism in clinical practice. J Intern Med. 2008;264(4):379–87.

    Article  CAS  PubMed  Google Scholar 

  215. Glaser JE, Chamarthy M, Haramati LB, et al. Successful and safe implementation of a trinary interpretation and reporting strategy for V/Q lung scintigraphy. J Nucl Med. 2011;52(10):1508–12.

    Article  PubMed  Google Scholar 

  216. Sostman HD, Stein PD, Gottschalk A, et al. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology. 2008;246(3):941–6.

    Article  PubMed  Google Scholar 

  217. Stein PD, Terrin ML, Gottschalk A, et al. Value of ventilation/perfusion scans vs. perfusion scans alone in acute pulmonary embolism. Am J Cardiol. 1992;69(14):1239–41.

    Article  CAS  PubMed  Google Scholar 

  218. Collart JP, Roelants V, Vanpee D, et al. Is a lung perfusion scan obtained by using single photon emission computed tomography able to improve the radionuclide diagnosis of pulmonary embolism? Nucl Med Commun. 2002;23(11):1107–13.

    Article  PubMed  Google Scholar 

  219. Corbus HF, Seitz JP, Larson RK, et al. Diagnostic usefulness of lung SPET in pulmonary thromboembolism: an outcome study. Nucl Med Commun. 1997;18(10):897–906.

    Article  CAS  PubMed  Google Scholar 

  220. Reinartz P, Wildberger JE, Schaefer W, et al. Tomographic imaging in the diagnosis of pulmonary embolism: a comparison between V/Q lung scintigraphy in SPECT technique and multislice spiral CT. J Nucl Med. 2004;45(9):1501–8.

    PubMed  Google Scholar 

  221. Gutte H, Mortensen J, Jensen CV, et al. Detection of pulmonary embolism with combined ventilation-perfusion SPECT and low-dose CT: head-to-head comparison with multidetector CT angiography. J Nucl Med. 2009;50(12):1987–92.

    Article  PubMed  Google Scholar 

  222. van Beek EJ, Reekers JA, Batchelor DA, et al. Feasibility, safety and clinical utility of angiography in patients with suspected pulmonary embolism. Eur Radiol. 1996;6(4):415–9.

    Article  PubMed  Google Scholar 

  223. Stein PD, Athanasoulis C, Alavi A, et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation. 1992;85(2):462–8.

    Article  CAS  PubMed  Google Scholar 

  224. Wan S, Quinlan DJ, Agnelli G, et al. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation. 2004;110(6):744–9.

    Article  CAS  PubMed  Google Scholar 

  225. Diffin DC, Leyendecker JR, Johnson SP, et al. Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. AJR Am J Roentgenol. 1998;171(4):1085–9.

    Article  CAS  PubMed  Google Scholar 

  226. Stein PD, Henry JW, Gottschalk A. Reassessment of pulmonary angiography for the diagnosis of pulmonary embolism: relation of interpreter agreement to the order of the involved pulmonary arterial branch. Radiology. 1999;210(3):689–91.

    Article  CAS  PubMed  Google Scholar 

  227. Zhang Y, Xia H, Wang Y, et al. The rate of missed diagnosis of lower-limb DVT by ultrasound amounts to 50% or so in patients without symptoms of DVT: a meta-analysis [published correction appears in Medicine (Baltimore)]. Medicine (Baltimore). 2019;98(37):e17103. https://doi.org/10.1097/MD.0000000000017103.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  228. Aujesky D, Perrier A, Roy PM, Stone RA, Cornuz J, Meyer G, Obrosky DS, Fine MJ. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med. 2007;261:597–604.

    Article  CAS  PubMed  Google Scholar 

  229. Barra SN, Paiva L, Providência R, Fernandes A, Marques AL. A review on state-of-the-art data regarding safe early discharge following admission for pulmonary embolism: what do we know? Clin Cardiol. 2013;36:507–15.

    Article  PubMed  PubMed Central  Google Scholar 

  230. Barra S, Paiva L, Providência R, Fernandes A, Nascimento J, Marques AL. LR-PED rule: low risk pulmonary embolism decision rule—a new decision score for low risk pulmonary embolism. Thromb Res. 2012;130:327–33.

    Article  CAS  PubMed  Google Scholar 

  231. Jiménez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, Otero R, Monreal M, Muriel A, Yusen RD, RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170:1383–9.

    Article  PubMed  Google Scholar 

  232. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685–713.

    Article  PubMed  Google Scholar 

  233. Choi BY, Park DG. Normalization of negative T-wave on electrocardiography and right ventricular dysfunction in patients with an acute pulmonary embolism. Korean J Intern Med. 2012;27:53–9.

    Article  PubMed  PubMed Central  Google Scholar 

  234. Golpe R, Castro-Anon O, Perez-de-Llano LA, et al. Electrocardiogram score predicts severity of pulmonary embolism in hemodynamically stable patients. J Hosp Med. 2011;6:285–9.

    Article  PubMed  Google Scholar 

  235. Kukla P, Dlstrokugopolski R, Krupa E, et al. Electrocardiography and prognosis of patients with acute pulmonary embolism. Cardiol J. 2011;18:648–53.

    Article  PubMed  Google Scholar 

  236. Daniel KR, Courtney DM, Kline JA. Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG. Chest. 2001;120:474–81.

    Article  CAS  PubMed  Google Scholar 

  237. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association [published corrections appear in Circulation. 2012;125:e495 and Circulation. 2012;126:e104]. Circulation. 2011;123:1788–830.

    Article  PubMed  Google Scholar 

  238. Hariharan P, Dudzinski DM, Okechukwu I, et al. Association between electrocardiographic findings, right heart strain, and short-term adverse clinical events in patients with acute pulmonary embolism. Clin Cardiol. 2015;38(4):236–42. https://doi.org/10.1002/clc.22383.

    Article  PubMed  PubMed Central  Google Scholar 

  239. Kukla P, Długopolski R, Krupa E, et al. The value of ECG parameters in estimating myocardial injury and establishing prognosis in patients with acute pulmonary embolism. Kardiol Pol. 2011;69:933–8.

    PubMed  Google Scholar 

  240. Punukollu G, Gowda RM, Vasavada BC, et al. Role of electrocardiography in identifying right ventricular dysfunction in acute pulmonary embolism. Am J Cardiol. 2005;96:450–2.

    Article  PubMed  Google Scholar 

  241. Douketis JD, Crowther MA, Stanton EB, Ginsberg JS. Elevated cardiac troponin levels in patients with submassive pulmonary embolism. Arch Intern Med. 2002;162(1):79–81. https://doi.org/10.1001/archinte.162.1.79.

    Article  CAS  PubMed  Google Scholar 

  242. Andrews J, MacNee W, Murchison J. Measurement of cardiac troponin identifies patients with moderate to large pulmonary emboli and right ventricular strain. Eur Respir J. 2014;44:P2407.

    Google Scholar 

  243. Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. Cardiac troponin I for predicting right ventricular dysfunction and intermediate risk in patients with normotensive pulmonary embolism. Neth Heart J. 2015;23(1):55–61. https://doi.org/10.1007/s12471-014-0628-7.

    Article  CAS  PubMed  Google Scholar 

  244. Tanindi A, Cemri M. Troponin elevation in conditions other than acute coronary syndromes. Vasc Health Risk Manag. 2011;7:597–603. https://doi.org/10.2147/VHRM.S24509.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  245. Sudoh T, Kangawa K, Minamino N, Matsuo H. A new natriuretic peptide in porcine brain. Nature. 1988;332:78–81.

    Article  CAS  PubMed  Google Scholar 

  246. Holmes SJ, Espiner EA, Richards AM, Yandle TG, Frampton C. Renal, endocrine, and hemodynamic effects of human brain natriuretic peptide in normal man. J Clin Endocrinol Metab. 1993;76:91–6.

    CAS  PubMed  Google Scholar 

  247. Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med. 1998;339:321–8.

    Article  CAS  PubMed  Google Scholar 

  248. Yoshimura M, Yasue H, Morita E, Sakaino N, Jougasaki M, Kurose M, et al. Hemodynamic, renal, and hormonal responses to brain natriuretic peptide infusion in patients with congestive heart failure. Circulation. 1991;84:1581–8.

    Article  CAS  PubMed  Google Scholar 

  249. Yasue H, Yoshimura M, Sumida H, Kikuta K, Kugiyama K, Jougasaki M, et al. Localization and mechanism of secretion of B-type natriuretic peptide in comparison with those of A-type natriuretic peptide in normal subjects and patients with heart failure. Circulation. 1994;90:195–203.

    Article  CAS  PubMed  Google Scholar 

  250. Coutance G, Le Page O, Lo T, Hamon M. Prognostic value of brain natriuretic peptide in acute pulmonary embolism. Crit Care. 2008;12(4):R109. https://doi.org/10.1186/cc6996.

    Article  PubMed  PubMed Central  Google Scholar 

  251. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. J Am Soc Echocardiogr. 2011;24:229–67.

    Article  PubMed  Google Scholar 

  252. Ten Wolde M, Söhne M, Quak E, Mac Gillavry MR, Büller HR. Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch Intern Med. 2004;164:1685–9.

    Article  PubMed  Google Scholar 

  253. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78:469–73.

    Article  CAS  PubMed  Google Scholar 

  254. Casazza F, Bongarzoni A, Capozi A, Agostoni O. Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11–4.

    Article  PubMed  Google Scholar 

  255. Lopez-Candales A, Eleswarapu A, Shaver J, Edelman K, Gulyasy B, Candales MD. Right ventricular outflow tract spectral signal: a useful marker of right ventricular systolic performance and pulmonary hypertension severity. Eur J Echocardiogr. 2010;11:509–15.

    Article  PubMed  Google Scholar 

  256. Lopez-Candales A, Edelman K, Gulyasy B, Candales MD. Differences in the duration of total ejection between right and left ventricles in chronic pulmonary hypertension. Echocardiography. 2011;28:509–15.

    Article  PubMed  Google Scholar 

  257. López-Candales A, Edelman K. Shape of the right ventricular outflow Doppler envelope and severity of pulmonary hypertension. Eur Heart J Cardiovasc Imaging. 2012;13:309–16.

    Article  PubMed  Google Scholar 

  258. Kurzyna M, Torbicki A, Pruszczyk P, Burakowska B, Fijałkowska A, Kober J, Oniszh K, Kuca P, Tomkowski W, Burakowski J, Wawrzyńska L. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol. 2002;90(5):507–11.

    Article  PubMed  Google Scholar 

  259. Gorham LW. A study of pulmonary embolism: two the mechanism of death based on a clinical pathological investigation of 100 cases of massive and 285 cases of minor embolism of the pulmonary artery. Arch Intern Med. 1961;108:76–90.

    Google Scholar 

  260. Del Guercio LRM, Cohn JDFNR. Pulmonary embolism shock: physiologic basis of a bedside screening test. JAMA. 1960;196:751–6.

    Article  Google Scholar 

  261. Urokinase Pulmonary Embolism Trial. Phase 1 results: a cooperative study. JAMA. 1970;214:2163–72.

    Google Scholar 

  262. Alpert JS, Smith R, Carlson J, et al. Mortality in patients treated for pulmonary embolism. JAMA. 1976;236:1477–80.

    Article  CAS  PubMed  Google Scholar 

  263. Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45:302–10.

    Article  PubMed  Google Scholar 

  264. Golpe R, Testa-Fernández A, Pérez-de-Llano LA, Castro-Añón O, González-Juanatey C, Pérez-Fernández R, Fariñas MC. Long-term clinical outcome of patients with persistent right ventricle dysfunction or pulmonary hypertension after acute pulmonary embolism. Eur J Echocardiogr. 2011;12:756–61.

    Article  PubMed  Google Scholar 

  265. Lo A, Stewart P, Younger JF, Atherton J, Prasad SB. Usefulness of right ventricular myocardial strain in assessment of response to thrombolytic therapy in acute pulmonary embolism. Eur J Echocardiogr. 2010;11:892–5.

    Article  PubMed  Google Scholar 

  266. McIntyre KM, Sasahara AA. Correlation of pulmonary photoscan and angiogram as measures of the severity of pulmonary embolic involvement. J Nucl Med. 1971;12:732–8.

    CAS  PubMed  Google Scholar 

  267. McDonald IG, Hirsh J, Hale GS, et al. Major pulmonary embolism, a correlation of clinical findings, haemodynamics, pulmonary angiography, and pathological physiology. Br Heart J. 1972;34:356–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  268. Dalen JE, Haynes FW, Hoppin FG, et al. Cardiovascular responses to experimental pulmonary embolism. Am J Cardiol. 1967;20:3–9.

    Article  Google Scholar 

  269. McIntyre KM, Sasahara AA. Hemodynamic and ventricular responses to pulmonary embolism. Prog Cardiovasc Dis. 1974;17:175–90.

    Article  CAS  PubMed  Google Scholar 

  270. Parker BM, Smith JR. Pulmonary embolism and infarction: a review of the physiologic consequences of pulmonary artery obstruction. Am J Med. 1958;24:402–27.

    Article  CAS  PubMed  Google Scholar 

  271. Stein M, Levy SE. Reflex and humoral responses to pulmonary embolism. Prog Cardiovasc Dis. 1974;17:167–74.

    Article  CAS  PubMed  Google Scholar 

  272. Malik AB. Pulmonary microembolism. Physiol Rev. 1983;63:1114–207.

    Article  CAS  PubMed  Google Scholar 

  273. Alpert JS, Godtfredsen J, Ockene IS, et al. Pulmonary hypertension secondary to minor pulmonary embolism. Chest. 1978;73:795–7.

    Article  CAS  PubMed  Google Scholar 

  274. Calvin JE Jr, Baer RW, Glantz SA. Pulmonary artery constriction produces a greater right ventricular dynamic afterload than lung microvascular injury in the open chest dog. Circ Res. 1985;56:40–56.

    Article  PubMed  Google Scholar 

  275. Stein PD, Sabbah HN, Anbe DT, et al. Performance of the failing and nonfailing right ventricle of patients with pulmonary hypertension. Am J Cardiol. 1979;44:1050–5.

    Article  CAS  PubMed  Google Scholar 

  276. Calvin JE, Quinn B. Right ventricular pressure overload during acute lung injury: cardiac mechanisms and the pathophysiology of right ventricular systolic dysfunction. J Crit Care. 1989;4:251–65.

    Article  Google Scholar 

  277. Calvin JE Jr. Acute right heart failure: pathophysiology, recognition, and pharmacological management. J Cardiothorac Vasc Anesth. 1991;5:507–13.

    Article  PubMed  Google Scholar 

  278. Taylor RR, Covell JW, Sonnenblick EH, et al. Dependence of ventricular distensibility on filling of the opposite ventricle. Am J Physiol. 1967;213:711–8.

    Article  CAS  PubMed  Google Scholar 

  279. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV Jr, Popovich J Jr, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK, PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317–27.

    Article  CAS  PubMed  Google Scholar 

  280. Martins SR. Pulmonary CT angiography in pulmonary embolism: beyond diagnosis. Rev Port Cardiol. 2012;31:697–9.

    Article  PubMed  Google Scholar 

  281. Apfaltrer P, Bachmann V, Meyer M, Henzler T, Barraza JM, Gruettner J, Walter T, Schoepf UJ, Schoenberg SO, Fink C. Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome. Eur J Radiol. 2012;81:3592–7.

    Article  PubMed  Google Scholar 

  282. Kang DK, Sun JS, Park KJ, Lim HS. Usefulness of combined assessment with computed tomographic signs of right ventricular dysfunction and cardiac troponin T for risk stratification of acute pulmonary embolism. Am J Cardiol. 2011;108:133–40.

    Article  PubMed  Google Scholar 

  283. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 2007;116:427–33.

    Article  CAS  PubMed  Google Scholar 

  284. Jiménez D, Uresandi F, Otero R, Lobo JL, Monreal M, Martí D, Zamora J, Muriel A, Aujesky D, Yusen RD. Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism: systematic review and metaanalysis. Chest. 2009;136:974–82.

    Article  PubMed  Google Scholar 

  285. Hunt JM, Bull TM. Clinical review of pulmonary embolism: diagnosis, prognosis, and treatment. Med Clin North Am. 2011;95:1203–22.

    Article  PubMed  Google Scholar 

  286. Stergiopoulos K, Bahrainy S, Strachan P, Kort S. Right ventricular strain rate predicts clinical outcomes in patients with acute pulmonary embolism. Acute Card Care. 2011;13:181–8.

    Article  PubMed  Google Scholar 

  287. Jiménez D, Aujesky D, Moores L, Gómez V, Martí D, Briongos S, Monreal M, Barrios V, Konstantinides S, Yusen RD. Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax. 2011;66:75–81.

    Article  PubMed  Google Scholar 

  288. Bellofiore A, Roldán-Alzate A, Besse M, Kellihan HB, Consigny DW, Francois CJ, Chesler NC. Impact of acute pulmonary embolization on arterial stiffening and right ventricular function in dogs. Ann Biomed Eng. 2013;41:195–204.

    Article  PubMed  Google Scholar 

  289. Champion HC, Michelakis ED, Hassoun PM. Comprehensive invasive and noninvasive approach to the right ventricle-pulmonary circulation unit: state of the art and clinical and research implications. Circulation. 2009;120:992–1007.

    Article  PubMed  Google Scholar 

  290. Kussmaul WG, Noordergraaf A, Laskey WK. Right ventricular-pulmonary arterial interactions. Ann Biomed Eng. 1992;20:63–80.

    Article  CAS  PubMed  Google Scholar 

  291. Parmley WW, Tyberg JV, Glantz SA. Cardiac dynamics. Annu Rev Physiol. 1977;39:277–99.

    Article  CAS  PubMed  Google Scholar 

  292. Piene H. Pulmonary arterial impedance and right ventricular function. Physiol Rev. 1986;66:606–52.

    Article  CAS  PubMed  Google Scholar 

  293. Milnor WR, Bergel DH, Bargainer JD. Hydraulic power associated with pulmonary blood flow and its relation to heart rate. Circ Res. 1966;19:467–80.

    Article  CAS  PubMed  Google Scholar 

  294. Piene H, Sund T. Flow and power output of right ventricle facing load with variable input impedance. Am J Physiol. 1979;237:H125–30.

    CAS  PubMed  Google Scholar 

  295. O’Rourke MF. Vascular impedance in studies of arterial and cardiac function. Physiol Rev. 1982;62:570–623.

    Article  PubMed  Google Scholar 

  296. Giannitsis E, Muller-Bardorff M, Kurowski V, et al. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation. 2000;102:211–7.

    Article  CAS  PubMed  Google Scholar 

  297. Konstantinides S, Geibel A, Olschewski M, et al. Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. Circulation. 2002;106:1263–8.

    Article  CAS  PubMed  Google Scholar 

  298. Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191–4.

    Article  PubMed  Google Scholar 

  299. Kucher N, Goldhaber SZ. Risk stratification of acute pulmonary embolism. Semin Thromb Hemost. 2006;32:838–47.

    Article  PubMed  Google Scholar 

  300. Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol. 2000;36:1632–6.

    Article  CAS  PubMed  Google Scholar 

  301. López-Candales A, Edelman K, Candales MD. Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited. Echocardiography. 2010;27:614–20.

    Article  PubMed  Google Scholar 

  302. Platz E, Hassanein AH, Shah A, Goldhaber SZ, Solomon SD. Regional right ventricular strain pattern in patients with acute pulmonary embolism. Echocardiography. 2012;29:464–70.

    Article  PubMed  Google Scholar 

  303. Descotes-Genon V, Chopard R, Morel M, Meneveau N, Schiele F, Bernard Y. Comparison of right ventricular systolic function in patients with low risk and intermediate-to-high risk pulmonary embolism: a two-dimensional strain imaging study. Echocardiography. 2013;30:301–8.

    Article  PubMed  Google Scholar 

  304. López-Candales A, Edelman K. Right ventricular outflow tract systolic excursion: a distinguishing echocardiographic finding in acute pulmonary embolism. Echocardiography. 2013;30(6):649–57.

    Article  PubMed  Google Scholar 

  305. Lopez-Candales A. Marked reduction in the ratio of main right ventricular chamber to outflow tract function in patients with proximal bilateral acute pulmonary embolism. Int J Cardiol. 2013;168(1):592–3.

    Article  PubMed  Google Scholar 

  306. Gorcsan J 3rd, Tanaka H. Echocardiographic assessment of myocardial strain. J Am Coll Cardiol. 2011;58:1401–13.

    Article  PubMed  Google Scholar 

  307. Huang SJ, Orde S. From speckle tracking echocardiography to torsion: research tool today, clinical practice tomorrow. Curr Opin Crit Care. 2013;19:250–7.

    Article  PubMed  Google Scholar 

  308. Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E, Støylen A, Ihlen H, Lima JA, Smiseth OA, Slørdahl SA. Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol. 2006;47:789–93.

    Article  PubMed  Google Scholar 

  309. Helle-Valle T, Crosby J, Edvardsen T, Lyseggen E, Amundsen BH, Smith HJ, Rosen BD, Lima JA, Torp H, Ihlen H, Smiseth OA. New noninvasive method for assessment of left ventricular rotation: speckle tracking echocardiography. Circulation. 2005;112:3149–56.

    Article  PubMed  Google Scholar 

  310. López-Candales A, Rajagopalan N, Gulyasy B, Edelman K, Bazaz R. Differential strain and velocity generation along the right ventricular free wall in pulmonary hypertension. Can J Cardiol. 2009;25:73–7.

    Article  Google Scholar 

  311. López-Candales A, Dohi K, Bazaz R, Edelman K. Relation of right ventricular free wall mechanical delay to right ventricular dysfunction as determined by tissue Doppler imaging. Am J Cardiol. 2005;96:602–6.

    Article  PubMed  Google Scholar 

  312. López-Candales A, Dohi K, Rajagopalan N, Suffoletto M, Murali S, Gorcsan J 3rd, Edelman K. Right ventricular dyssynchrony in patients with pulmonary hypertension is associated with disease severity and functional class. Cardiovasc Ultrasound. 2005;3(1):23.

    Article  PubMed  PubMed Central  Google Scholar 

  313. Rajagopalan N, Dohi K, Simon MA, Suffoletto M, Edelman K, Murali S, López-Candales A. Right ventricular dyssynchrony in heart failure: a tissue Doppler imaging study. J Card Fail. 2006;12:263–7.

    Article  PubMed  Google Scholar 

  314. Dohi K, Onishi K, Gorcsan J 3rd, López-Candales A, Takamura T, Ota S, Yamada N, Ito M. Role of radial strain and displacement imaging to quantify wall motion dyssynchrony in patients with left ventricular mechanical dyssynchrony and chronic right ventricular pressure overload. Am J Cardiol. 2008;101:1206–12.

    Article  PubMed  Google Scholar 

  315. Sugiura E, Dohi K, Onishi K, Takamura T, Tsuji A, Ota S, Yamada N, Nakamura M, Nobori T, Ito M. Reversible right ventricular regional non-uniformity quantified by speckle-tracking strain imaging in patients with acute pulmonary thromboembolism. J Am Soc Echocardiogr. 2009;22:1353–9.

    Article  PubMed  Google Scholar 

  316. Taccardi B, Lux RL, Ershler PR, et al. Anatomical architecture and electrical activity of the heart. Acta Cardiol. 1997;52:91–105.

    CAS  PubMed  Google Scholar 

  317. Torrent-Guasp F, Buckberg GD, Clemente C, et al. The structure and function of the helical heart and its buttress wrapping: I. The normal macroscopic structure of the heart. Semin Thorac Cardiovasc Surg. 2001;134:301–19.

    Article  Google Scholar 

  318. Sullivan DM, Watts JA, Kline JA. Biventricular cardiac dysfunction after acute massive pulmonary embolism in the rat. J Appl Physiol. 2001;90:1648–56.

    Article  CAS  PubMed  Google Scholar 

  319. Chua JH, Zhou W, Ho JK, Patel NA, Mackensen GB, Mahajan A. Acute right ventricular pressure overload compromises left ventricular function by altering septal strain and rotation. J Appl Physiol. 2013;115:186–93.

    Article  PubMed  PubMed Central  Google Scholar 

  320. Ichikawa K, Dohi K, Sugiura E, Sugimoto T, Takamura T, Ogihara Y, Nakajima H, Onishi K, Yamada N, Nakamura M, Nobori T, Ito M. Ventricular function and dyssynchrony quantified by speckle-tracking echocardiography in patients with acute and chronic right ventricular pressure overload. J Am Soc Echocardiogr. 2013;26:483–92.

    Article  PubMed  Google Scholar 

  321. López-Candales A, Bazaz R, Edelman K, Gulyasy B. Altered early left ventricular diastolic wall velocities in pulmonary hypertension: a tissue Doppler study. Echocardiography. 2009;26:1159–66.

    Article  PubMed  Google Scholar 

  322. Egermayer P, Town GI. The clinical significance of pulmonary embolism: uncertainties and implications for treatment: a debate. J Intern Med. 1997;241:5–10.

    Article  CAS  PubMed  Google Scholar 

  323. Freiman DG, Suyemoto J, Wessler S. Frequency of pulmonary thromboembolism in man. N Engl J Med. 1965;272:1278–80.

    Article  CAS  PubMed  Google Scholar 

  324. Havig O. Deep vein thrombosis and pulmonary embolism: an autopsy study with multiple regression analysis of possible risk factors. Acta Chir Scand. 1977;478(Suppl):1–108.

    CAS  Google Scholar 

  325. Wagenvoort CA. Pathology of pulmonary thromboembolism. Chest. 1995;107(Suppl):10S–7S.

    Article  CAS  PubMed  Google Scholar 

  326. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019;54:1901647.

    Article  PubMed  Google Scholar 

  327. Klok FA, Mos IC, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168:2131–6.

    Article  PubMed  Google Scholar 

  328. Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247–55.

    Article  CAS  PubMed  Google Scholar 

  329. Geersing GJ, Janssen KJ, Oudega R, et al. Excluding venous thromboembolism using point of care D-dimer tests in outpatients: a diagnostic meta-analysis. BMJ. 2009;339:b2990.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  330. Elias A, Mallett S, Daoud-Elias M, et al. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open. 2016;6:e010324.

    Article  PubMed  PubMed Central  Google Scholar 

  331. Kohn CG, Mearns ES, Parker MW, et al. Prognostic accuracy of clinical prediction rules for early post-pulmonary embolism all-cause mortality: a bivariate meta-analysis. Chest. 2015;147:1043–62.

    Article  PubMed  Google Scholar 

  332. Guerin L, Couturaud F, Parent F, et al. Prevalence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Prevalence of CTEPH after pulmonary embolism. Thromb Haemost. 2014;112:598–605.

    Article  CAS  PubMed  Google Scholar 

  333. Galie N, Humbert M, Vachiery JL, Gibbs S, et al., ESC Scientific Document Group. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37:67–119.

    Google Scholar 

  334. Vonk Noordegraaf A, Marcus JT, Roseboom B, Postmus PE, Faes TJ, de Vries PM. The effect of right ventricular hypertrophy on left ventricular ejection fraction in pulmonary emphysema. Chest. 1997;112:640–5.

    Article  CAS  PubMed  Google Scholar 

  335. Pieralli F, Olivotto I, Vanni S, Conti A, Camaiti A, Targioni G, Grifoni S, Berni G. Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism. Am J Cardiol. 2006;97:1386–90.

    Article  CAS  PubMed  Google Scholar 

  336. Kostrubiec M, Pruszczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, Styczynski G, Kuch-Wocial A, Abramczyk P, Bartoszewicz Z, Berent H, Kuczynska K. Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J. 2005;26:2166–72.

    Article  CAS  PubMed  Google Scholar 

  337. Ghuysen A, Ghaye B, Willems V, Lambermont B, Gerard P, Dondelinger RF, D’Orio V. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax. 2005;60:956–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  338. Tulevski II, ten Wolde M, van Veldhuisen DJ, Mulder JW, van der Wall EE, Büller HR, Mulder BJ. Combined utility of brain natriuretic peptide and cardiac troponin T may improve rapid triage and risk stratification in normotensive patients with pulmonary embolism. Int J Cardiol. 2007;116:161–6.

    Article  PubMed  Google Scholar 

  339. Tulevski II, Hirsch A, Sanson BJ, Romkes H, van der Wall EE, van Veldhuisen DJ, Büller HR, Mulder BJ. Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost. 2001;86:1193–6.

    Article  CAS  PubMed  Google Scholar 

  340. Vieillard-Baron A, Page B, Augarde R, Prin S, Qanadli S, Beauchet A, Dubourg O, Jardin F. Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate. Intensive Care Med. 2001;27:1481–6.

    Article  CAS  PubMed  Google Scholar 

  341. Kucher N, Printzen G, Doernhoefer T, Windecker S, Meier B, Hess OM. Low pro-brain natriuretic peptide levels predict benign clinical outcome in acute pulmonary embolism. Circulation. 2003;107:1576–8.

    Article  PubMed  Google Scholar 

  342. ten Wolde M, Tulevski II, Mulder JW, Sohne M, Boomsma F, Mulder BJ, Buller HR. Brain natriuretic peptide as a predictor of adverse outcome in patients with pulmonary embolism. Circulation. 2003;107:2082–4.

    Article  PubMed  Google Scholar 

  343. Pruszczyk P, Kostrubiec M, Bochowicz A, Styczynski G, Szulc M, Kurzyna M, Fijalkowska A, Kuch-Wocial A, Chlewicka I, Torbicki A. N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J. 2003;22:649–53.

    Article  CAS  PubMed  Google Scholar 

  344. Moser KM, Auger WR, Fedullo PF. Chronic major-vessel thromboembolic pulmonary hypertension. Circulation. 1990;81:1735–43.

    Article  CAS  PubMed  Google Scholar 

  345. Matthews DT, Hemnes AR. Current concepts in the pathogenesis of chronic thromboembolic pulmonary hypertension. Pulm Circ. 2016;6:145–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  346. Moser KM, Bloor CM. Pulmonary vascular lesions occurring in patients with chronic major vessel thromboembolic pulmonary hypertension. Chest. 1993;103:685–92.

    Article  CAS  PubMed  Google Scholar 

  347. Galiè N, Kim NH. Pulmonary microvascular disease in chronic thromboembolic pulmonary hypertension. Proc Am Thorac Soc. 2006;3:571–6.

    Article  PubMed  Google Scholar 

  348. Pepke-Zaba J, Delcroix M, Lang I, et al. Chronic Thromboembolic Pulmonary Hypertension (CTEPH): results from an international prospective registry. Circulation. 2011;124:1973–81.

    Article  PubMed  Google Scholar 

  349. Ende-Verhaar YM, Cannegieter SC, Vonk Noordegraaf A, et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J. 2017;49:1601972.

    Article  Google Scholar 

  350. Sanchez O, Helley D, Couchon S, et al. Perfusion defects after pulmonary embolism: risk factors and clinical significance. J Thromb Haemost. 2010;8:1248–55.

    Article  CAS  PubMed  Google Scholar 

  351. Pesavento R, Filippi L, Palla A, et al. Impact of residual pulmonary obstruction on the long-term outcome of patients with pulmonary embolism. Eur Respir J. 2017;49:1601980.

    Article  PubMed  Google Scholar 

  352. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016;41:3–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  353. Pengo V, Lensing AWA, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257–64.

    Article  CAS  PubMed  Google Scholar 

  354. Becattini C, Agnelli G, Pesavento R, et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest. 2006;130:172–5.

    Article  PubMed  Google Scholar 

  355. Klok FA, van Kralingen KW, van Dijk AP, et al. Prospective cardiopulmonary screening program to detect chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism. Haematologica. 2010;95:970–5.

    Article  PubMed  PubMed Central  Google Scholar 

  356. Dentali F, Donadini M, Gianni M, et al. Incidence of chronic pulmonary hypertension in patients with previous pulmonary embolism. Thromb Res. 2009;124:256–8.

    Article  CAS  PubMed  Google Scholar 

  357. Klok FA, Dzikowska-Diduch O, Kostrubiec M, et al. Derivation of a clinical prediction score for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. J Thromb Haemost. 2016;14:121–8.

    Article  CAS  PubMed  Google Scholar 

  358. Ribeiro A, Lindmarker P, Johnsson H, et al. Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis. Circulation. 1999;99:1325–30.

    Article  CAS  PubMed  Google Scholar 

  359. Bonderman D, Wilkens H, Wakounig S, et al. Risk factors for chronic thromboembolic pulmonary hypertension. Eur Respir J. 2009;33:325–31.

    Article  CAS  PubMed  Google Scholar 

  360. Klok FA, Barco S, Konstantinides SV, et al. Determinants of diagnostic delay in chronic thromboembolic pulmonary hypertension: results from the European CTEPH Registry. Eur Respir J. 2018;52:1801687.

    Article  PubMed  Google Scholar 

  361. Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2018;53:1801913.

    Article  CAS  Google Scholar 

  362. Papamatheakis GD, Poch DS, Fernandes TM, et al. Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2020;76:2155–69.

    Article  PubMed  Google Scholar 

  363. Ryan KL, Fedullo PF, Davis GB, et al. Perfusion scan findings understate the severity of angiographic and hemodynamic compromise in chronic thromboembolic pulmonary hypertension. Chest. 1988;93:1180–5.

    Article  CAS  PubMed  Google Scholar 

  364. He J, Fang W, Lv B, et al. Diagnosis of chronic thromboembolic pulmonary hypertension: comparison of ventilation/perfusion scanning and multidetector computed tomography pulmonary angiography with pulmonary angiography. Nucl Med Commun. 2012;33:459–63.

    Article  PubMed  Google Scholar 

  365. Sugiura T, Tanabe N, Matsuura Y, et al. Role of 320-slice CT imaging in the diagnostic workup of patients with chronic thromboembolic pulmonary hypertension. Chest. 2013;143:1070–7.

    Article  PubMed  Google Scholar 

  366. Rogberg AN, Gopalan D, Westerlund E, et al. Do radiologists detect chronic thromboembolic disease on computed tomography. Acta Radiol. 2019;60:1576–83.

    Article  PubMed  Google Scholar 

  367. Hoeper MM, Madani M, Nakanishi N, et al. Chronic thromboembolic pulmonary hypertension. Lancet Respir Med. 2014;2:573–82.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiovascular Diseases, Truman Medical Center, Hospital Hill, University of Missouri-Kansas City, Kansas City, MO, USA

    Angel López-Candales

  2. Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA

    Srikanth Vallurupalli

Authors
  1. Angel López-Candales
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  2. Srikanth Vallurupalli
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Correspondence to Angel López-Candales .

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Editors and Affiliations

  1. National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland

    Sean P. Gaine

  2. Free University of Brussels, Brussels, Belgium

    Robert Naeije

  3. Scottish Pulmonary Vascular Unit, Regional Heart and Lung Centre, Glasgow, UK

    Andrew J. Peacock

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López-Candales, A., Vallurupalli, S. (2021). Pulmonary Embolism. In: Gaine, S.P., Naeije, R., Peacock, A.J. (eds) The Right Heart. Springer, Cham. https://doi.org/10.1007/978-3-030-78255-9_14

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