| Part 1.A real-world study of the clinical characteristics and treatment of acute pulmonary embolism Objective:To study the clinical manifestation,laboratory examination,imaging features and treatment status of acute pulmonary embolism patients.Methods:1.The demographics,clinical symptoms,laboratory tests,imaging features and treatment strategies of clinically diagnosed acute pulmonary embolism patients admitted to the Department of Cardiovascular Medicine of the First Hospital of Jilin University from August 2018 to March 2022 were retrospectively analyzed.According to the guideline standard risk stratification of acute pulmonary embolism,the selected cases were divided into low-risk group,medium-low risk group,mediumhigh risk group and high risk group.2.Clinical manifestations,hypertension,diabetes and smoking history,arterial blood gas analysis,blood cell count,biochemistry,D-dimer,myocardial injury markers,BNP and other laboratory test results,electrocardiogram,echocardiography,lower extremity venous ultrasound,and treatment strategies,including thrombolysis,anticoagulation and interventional therapy,were collected.3.CTPA and radionuclide imaging features of APTE,chronic thromboembolic pulmonary hypertension(CTEPH)and pulmonary sarcoma(PAS)were studied and identified by clinical cases.4.SPSS26 software was used for statistical analysis.Measurement data that did not conform to normal distribution were represented by median M(Q1,Q3),and Kruskal-Wallis rank sum test was performed for comparison between groups.The statistical data were represented by the number of cases and percentage [n(%)],χ2test was compared between groups,and Fisher exact probability method was used if the sample size was small or did not meet the Chi-square test standard.Spearman correlation analysis was used to analyze the correlation between the measured values.P < 0.05 was considered to be statistically significant.Results:1.A total of 618 patients with acute pulmonary embolism were clinically diagnosed in the Department of Cardiovascular Medicine of the First Hospital of Jilin University from August 2018 to March 2022,including 301 females(48.7%)and 317males(51.3%),aged 20-92 years,with an average age of 66(58,72)years.There were53 cases(8.6%)in the low risk group,294 cases(47.6%)in the low risk group,251cases(40.6%)in the high risk group,and 20 cases(3.2%)in the high risk group.There were 9 deaths(1.5%)during hospitalization.2.The clinical manifestations of acute pulmonary embolism included dyspnea in449 cases(72.7%),chest pain in 173 cases(28.0%),cough in 39 cases(6.3%),syncope in 38 cases(6.1%),hemoptysis in 31 cases(5.0%).There were 209 patients with hypertension(33.8%),68 patients with diabetes(11.0%),153 patients with smoking history(24.8%),and 464 patients with deep venous thrombosis of lower limbs(75.1%).Treatment strategy: 513 cases(83.0%)were treated with anticoagulation alone,101 cases(16.3%)were treated with thrombolytic sequential anticoagulation.16 cases(2.6%)were treated with ventilator.3.LDL-C in different risk groups was different(P < 0.05),and the level of LDL-C in high-risk group was lower.c Tn I,BNP,D-dimer,Cr,AST,ALT were significantly positively correlated with the risk stratification of acute pulmonary embolism(P < 0.05),while PO2,PLT were significantly negatively correlated with the risk stratification of acute pulmonary embolism(P < 0.05).4.Heart rate and frontal QRS-T Angle were positively correlated with risk stratification in patients with acute pulmonary embolism(P<0.05).There was a significant positive correlation between echocardiographic indexes RA,RV and PG and the risk stratification of patients with acute pulmonary embolism(P<0.05).5.CTPA imaging of acute pulmonary embolism showed high thrombotic load involving the main pulmonary artery and/or the left and right pulmonary trunk,and 11cases(20.8%)in the low-risk group,105 cases(35.7%)in the low-risk group,152cases(60.6%)in the high-risk group,and 10 cases(50.0%)in the high-risk group.Comparison among the four groups was P < 0.05.6.CTPA images of acute pulmonary embolism,CTEPH and PAS all showed filling defects in the pulmonary lumen.Acute pulmonary embolism is characterized by a filling defect floating in the lumen,and the filling defect of CTEPH is attached to the tube wall.PAS is an invasive growth that can spread directly beyond the pulmonary artery wall.Conclusions:1.Most patients with acute pulmonary embolism are middle-aged,and dyspnea is the most common clinical symptom.Some patients with acute pulmonary embolism have atherosclerosis risk factors.About 3/4 of patients with acute pulmonary embolism have deep venous thrombosis of lower limbs.The in-hospital mortality rate for acute pulmonary embolism is 1.5%.2.c Tn I,BNP,D-dimer,Cr,AST,ALT,PO2,and PLT can be used to evaluate the prognosis of acute pulmonary embolism.3.Heart rate and frontal QRS-T Angle can be used to evaluate the prognosis of patients with acute pulmonary embolism.Echocardiographic indicators RA,RV and PG can be used to evaluate the prognosis of patients with acute pulmonary embolism.4.Pharmacologic strategies for acute pulmonary embolism include anticoagulation and thrombolysis,and ventilator-assisted support may be used in severe cases.5.The CTPA of patients with acute pulmonary embolism in middle and high risk groups showed high thrombotic load.6.Typical CTPA images of acute pulmonary embolism,CTEPH and PAS have certain characteristics.Radionuclide imaging is helpful for the diagnosis of PAS.Part 2.Phenotype and genetic family study of embolism in acute pulmonary embolism Objective:To investigate the risk factors of VTE in patients with acute pulmonary embolism,and analyze the proportion of genetic thromboembolism such as protein S deficiency,protein C deficiency,antithrombin Ⅲ deficiency,hyperhomocysteinemia in acute pulmonary embolism,as well as acute pulmonary embolism related to thromboembolism such as nephrotic syndrome.Methods:1.Retrospectively analyzed clinically diagnosed acute pulmonary embolism patients admitted to the Department of Cardiovascular Medicine of the First Hospital of Jilin University from August 2018 to March 2022.2.The risk factors of VTE were: fracture,operation within 4 weeks of onset,tumor,elevated anti-phospholipid antibody.The number of cases of hereditary thromboembolism,including protein S deficiency,antithrombin III deficiency,protein C deficiency and homocysteine elevation were calculated.3.Analysis of typical cases and gene mutation sites of protein C deficiency related thrombolism.Analysis of typical cases,gene mutation sites and family study of hereditary protein S deficiency and antithrombin III deficiency.4.Analysis of typical cases of acute pulmonary embolism associated with nephrotic syndrome and other thromboembolic diseases.5.Statistical analysis was performed using SPSS26 software.The statistical data were represented by the number of cases and percentage [n(%)],χ2 test was compared between groups,and Fisher exact probability method was used if the sample size was small or did not meet the Chi-square test standard.P< 0.05 was considered to be statistically significant.Results:1.Among 618 patients with acute pulmonary embolism clinically diagnosed from August 2018 to March 2022 in the Department of Cardiovascular Medicine of the First Hospital of Jilin University,the risk factors for acquired VTE included 41 cases of fracture(6.6%),96 cases of operation within 4 weeks of onset(15.5%),46 cases of tumor(7.4%),and 135 cases of elevated antiphospholipid antibody(21.8%).2.In 618 patients with acute pulmonary embolism,the activity of anticoagulant protein was abnormal: the activity of protein S was decreased in 70 cases(11.3%),the activity of protein C was decreased in 97 cases(15.7%),and the activity of antithrombin III was decreased in 111 cases(18.0%).There were 104 cases(16.8%)with elevated homocysteine,and BHMT gene mutation was detected in the cases with elevated homocysteine.There were no significant differences in anticoagulant protein abnormality,homocysteine increase and antiphospholipid antibody increase among the four groups(P>0.05).3.Protein C deficiency cases are protein C gene mutation: PROCc.1000G>A,which is a missense mutation.The genetic protein S deficiency family is a protein S gene mutation: PROSc.200A>C,which is a missense mutation.The genetic antithrombin Ⅲ deficiency family was the ATⅢ gene mutation: SERPINC1 c.331T>C,which was a missense mutation.Both families showed autosomal dominant inheritance.4.The pathological type of acute pulmonary embolism associated with nephrotic syndrome is glomerular micropathy.Conclusions:1.Fracture,operation within 4 weeks of onset,tumor,elevated antiphospholipid antibody and other factors can lead to the formation of VTE,which is a common acquired thromboembolic disease in acute pulmonary embolism.2.Protein S deficiency,protein C deficiency and antithrombin III deficiency are common hereditary thromboembolic factors in Chinese patients with acute pulmonary embolism.Mutations in the BHMT gene can lead to hyperhomocysteine-associated acute pulmonary embolism.3.The causal diagnosis of acute pulmonary embolism helps to detect hereditary thromboembolism,and the thromboembolism family can be found through the proband.Anticoagulant therapy and VTE monitoring should be strengthened for nephrotic syndrome and other thrombotic diseases.Part 3.Effects of examination,test indexes and treatment strategies on right heart dysfunction in patients with acute pulmonary embolism during follow-up Objective:To investigate the relationship between ECG and echocardiographic indicators and risk stratification of acute pulmonary embolism.To investigate the risk factors of right heart dysfunction after 3 months of acute pulmonary embolism treatment and the effect of thrombolytic therapy on it in the middle and high risk group.Methods:1.Retrospective analysis was performed on patients diagnosed with acute pulmonary embolism in the Department of Cardiovascular Medicine of the First Hospital of Jilin University from August 2018 to March 2022 who had follow-up information after 3 months of treatment.2.Ecg related indexes were collected,including heart rate,P-R interval,QRS time,frontal QRS-T Angle,etc.The relevant indexes of right heart structure and function in echocardiography included RA(mean value of upper and lower diameters and left and right diameters),RV,tricuspid regurgitation PG and SPAP.3.Among the above patients with acute pulmonary embolism,170 patients with follow-up information 3 months after treatment were divided into right heart dysfunction group and no right heart dysfunction group(control group)according to whether RV > 28 mm,RA upper and lower diameter > 50 mm or left and right diameter > 40 mm,and SPAP > 40 mm Hg on echocardiography.4.Patients in the middle risk group with follow-up information after 3 months of treatment were divided into thrombolysis group and anticoagulation group,and the number of cases of right heart dysfunction was counted respectively.5.SPSS26 software was used for statistical analysis.Measurement data conforming to normal distribution were expressed as mean±standard deviation((?)± s)and independent sample T-test was performed for inter-group comparison.Measurement data that did not conform to the normal distribution were represented by the median M(Q1,Q3),and Mann-Whitney U test was performed for comparison between groups.The statistical data were represented by the number of cases and percentage [n(%)],χ2 test was compared between groups,and Fisher exact probability method was used if the sample size was small or did not meet the Chisquare test standard.Logistic regression model was used to adjust confounding factors and single or multi-factor regression analysis was performed.P < 0.05 was considered to be statistically significant.Results:1.There were 170 patients with complete follow-up information after 3 months of treatment for acute pulmonary embolism.There were 49 cases(28.8%)with right heart dysfunction and 121 cases(71.2%)without right heart dysfunction.There were significant differences in age,BNP,LDL-C,heart rate,RA,RV and tricuspid regurgitant PG between the two groups(P<0.05).2.Multivariate regression analysis showed that RA was a risk factor for right heart dysfunction(OR=1.173,95%CI: 1.021 ~ 1.348,P=0.024).LDL-C was a protective factor for right heart dysfunction(OR=0.407,95%CI: 0.191-0.869,P=0.020).3.The incidence of right heart dysfunction in patients with acute pulmonary embolism after 3 months of thrombolytic therapy and anticoagulation therapy was15.0% and 51.8%,respectively,and the comparison between the two groups was P <0.05.Multivariate logistic regression analysis showed that the risk of right heart dysfunction in the anticoagulant group was 5.536 times higher than that in the thrombolytic group.Conclusions:1.RA diameter at admission is an independent risk factor for right heart dysfunction 3 months after treatment for acute pulmonary embolism,while LDL-C may be a protective factor,but further validation is needed in multicenter,prospective studies.2.Thrombolytic therapy can significantly reduce the occurrence of right heart dysfunction 3 months after treatment in patients with acute pulmonary embolism in the middle and high risk group.Part 4.Study on the efficacy and safety of percutaneous pulmonary thrombus aspiration and thrombectomy for acute pulmonary embolism Objective:APTE thrombus removal in pulmonary artery includes drug thrombolysis and interventional therapy.Interventional thrombolysis and thrombolysis instruments in China are still in the research and development stage.This study evaluated the efficacy and safety of percutaneous pulmonary artery thrombus aspiration and thrombus removal for acute pulmonary embolism in middle-risk APTE patients with domestic instruments.Methods:1.Patients diagnosed with acute pulmonary embolism in the intermediate risk group(CTPA imaging RV/LV maximum diameter ratio ≧ 0.9)who underwent percutaneous interventional pulmonary thrombus aspiration and thrombolysis from February 2023 to December 2023 in the Department of Cardiovascular Medicine,the First Hospital of Jilin University.2.Clinical data such as risk stratification and symptoms were collected,and preoperative and postoperative clinical symptoms were compared.The preoperative and postoperative clinical symptoms,pulmonary angiography and CTPA images,echocardiographic indicators(including RV,RA,SPAP),and PAP(SPAP,DPAP,MPAP)were compared.3.SPSS26 software was used for statistical analysis.Measurement data conforming to normal distribution were expressed as mean±standard deviation((?)±s),and independent sample T-test was performed for inter-group comparison.The statistical data were represented by the number of cases and percentage [n(%)],χ2test was compared between groups,and Fisher exact probability method was used if the sample size was small or did not meet the Chi-square test standard.Paired data,measurement data conforming to normal distribution were expressed as mean ±standard deviation(X±s),and paired T-test was performed for comparison between groups.Measures that did not conform to the normal distribution were expressed as the median M(Q1,Q3),and the Wilcoxon signed rank sum test was performed for comparison between groups.P < 0.05 was considered to be statistically significant.Results:1.In the Department of Cardiovascular Medicine of the First Hospital of Jilin University from February 2023 to December 2023,19 patients in the medium risk group who were diagnosed with acute pulmonary embolism and underwent percutaneous pulmonary thrombosis and embolectomy were all in the medium risk group,including 7 cases(36.8%)in the medium low risk group and 12 cases(63.2%)in the medium high risk group.2.The symptoms of dyspnea were significantly relieved in all the 19 patients.Both pulmonary arteriography and CTPA showed that thrombus load decreased significantly.3.Compared with before interventional surgery,RV(25.23±4.34 mm vs29.24±5.18 mm,P<0.05)and RA(41.86±4.59 mm vs 47.83±4.93 mm,P<0.05)were significantly decreased.4.Compared with before interventional surgery,Pulmonary artery pressure SPAP[36(30,44)mm Hg vs 64(55,69)mm Hg,P<0.05] 、 DPAP(14.37± 7.14 mm Hg vs23.74 ± 7.15 mm Hg,P<0.05)、 MPAP(23.89 ± 8.30 mm Hg vs 35.32 ±7.90 mm Hg,P<0.05)were significantly decreased.5.The condition and vital signs of 19 patients were stable during hospitalization,and there were no malignant arrhythmias,heart failure,bleeding requiring intervention and death.Conclusions:Percutaneous interventional pulmonary thrombus aspiration and thrombectomy can effectively remove pulmonary thrombus,improve the clinical symptoms of dyspnea,reduce pulmonary pressure and relieve the right ventricular load.Percutaneous pulmonary thrombus aspiration and thrombectomy are safe and effective in the treatment of acute pulmonary embolism. |
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