J Thromb Thrombolysis
DOI 10.1007/s11239-016-1438-0
Estimation of right ventricular dysfunction by computed
tomography pulmonary angiography: a valuable adjunct for
evaluating the severity of acute pulmonary embolism
DongJia1,3 Xiao-mingZhou2 GangHou3
Springer Science+Business Media New York 2016
Abstract To evaluate the feasibility and the efficacy of
computed tomography pulmonary angiography (CTPA) in
differentiating acute pulmonary embolism (PE) patients with
or without right ventricular dysfunction and to evaluate the
severity of right ventricular dysfunction in acute PE patients
with CPTA. We retrospectively collected and measured the
following parameters: right ventricular diameter by short
axis in the axial plane (RVDaxial), left ventricular diameter
by short axis in the axial plane (LVDaxial), right ventricular
diameter by level on the reconstructed four-chamber views
(RVD4CH), left ventricular diameter by level on the recon-
structed four-chamber views (LVD4CH), main pulmonary
artery diameter (MPAD), ascending aorta diameter (AOD),
coronary sinus diameter (CSD), superior vena cava diam-
eter (SVCD), inferior vena cava (IVC) reflux and interven-
tricular septum deviation by CTPA, and we calculated the
RVDaxial/LVDaxial, RVD4CH/LVD4CH and MPAD/AOD
ratios in acute PE patients. We assessed right ventricular
function and pulmonary artery systolic pressure (PASP) by
echocardiography (ECHO) and then divided the patients
into two groups: group A had right ventricular dysfunction,
and group B did not have right ventricular dysfunction. We
utilized a logistic regression model to analyse the relation-
ship between right ventricular dysfunction and the measure-
ment parameters obtained from CTPA, and we constructed
Gang Hou
hougangcmu@163.com
1
Department of Emergency, Shengjing Hospital of China
Medical University, Shenyang 110004, China
2
Department of Respiratory Medicine, Shengjing Hospital of
China Medical University, Shenyang 110004, China
3
Institute of Respiratory Disease, The First Hospital of China
Medical University, Shenyang 110001, China
the ROC curve to confirm the optimal cut-off value of the
statistically significant parameter in the logistic regression
model. After an initial screening, 113 acute PE patients were
enrolled in our study. Among them, 42 patients showed
right ventricular dysfunction (37.2 %), and 71 patients
showed no right ventricular dysfunction (62.8%). The dif-
ference between the patients with right ventricular dysfunc-
tion and patients without right ventricular dysfunction was
statistical significant in RVD4CH/LVD4CH ratio. Logistic
regression model analysis revealed that RVDaxial/LVDaxial
ratio and interventricular septum deviation were correlated
to right ventricular dysfunction with statistical significance
(p=0.001 and 0.03 respectively). RVDaxial/LVDaxial>1.02
(95% CI: 0.8180.958, p<0.0001, sensitivity: 90.2%,
specificity: 88.7%) and RVD4CH/LVD4CH ratio>0.999
(95% CI 0.7220.898, p<0.0001) were determined as the
optimal cut-off values following ROC analysis. There was
a positive correlation between the MPAD/AOD ratio and
PASP (r=0.408, p=0.01). Based on the analysis of the
parameters obtained by CTPA, the RVDaxial/LVDaxial ratio
and interventricular septum deviation could be utilized for
predicting right ventricular dysfunction. The MPAD/AOD
ratio is a potential adjunct to judge the severity of right
ventricular dysfunction in acute PE.
Keywords Pulmonary embolism Computed
tomography pulmonary angiography Right ventricular
dysfunction Echocardiography
Introduction
Acute pulmonary embolism (PE) is a common cardiopul-
monary emergency and severe disease and is the third lead-
ing cause of death by cardiopulmonary system diseases
13
2 D. Jia et al.
[1, 2]. In principle, risk stratification of acute PE is gen-
erally divided into a high-risk group, an intermediate-risk
group, and a low-risk group. Haemodynamically unstable
acute PE patients would be classified as a high-risk group
with a high mortality. Once an acute PE patient with hae-
modynamic instability is diagnosed, close monitoring and
an urgent reperfusion treatment must be initially taken into
account, due to its high mortality [3]. However, a majority
of acute PE patients are normotensive. It is reported that
approximately 80% of acute PE patients are normotensive
[4, 5]. Normotensive acute PE patients are not absolutely
stable. Haemodynamically stable acute PE patients with a
right ventricular dysfunction have a worse prognosis than
patients without right ventricular dysfunction [6, 7], and
they also need close monitoring and reperfusion treatment.
Patient deaths from acute PE generally occur within the
first 4h after admission to the hospital [8]. Thus, the time
involved in evaluating acute PE patients with or without
right ventricular dysfunction is precious. Although echo-
cardiography (ECHO) is the standard for the evaluation
of right ventricular dysfunction, conducting an echocar-
diography requires an ultrasound specialist, who may not
be available all the time in many hospitals [8]. Finding a
simple and effective method for identifying right ventricu-
lar dysfunction and evaluating its severity is essential for
emergency department physician. Computed tomography
pulmonary angiography (CTPA) is more convenient and
has been widely used for diagnosing and excluding acute
PE [9, 10]. But CTPA should be used appropriately. One is
mastering the indication of CTPA according to the analysis
of risk and possibility of PE [11], the other is careful analysis
of CTPA with reconstructive techniques which can provide
more useful information for the making of clinical strategy.
Evaluating right ventricular (RV) function by CTPA may be
time saving and reasonable. However, there have been few
studies focused on this topic. Aiming to evaluate the value
of CTPA image analysis in the diagnosis of right ventricu-
lar dysfunction in acute PE, we retrospectively collected
the relevant cardiovascular parameters, measured by CTPA
and ECHO in acute PE patients to explore the relationship
between these observed parameters and right ventricular
dysfunction, particularly in correlation with the pulmonary
artery systolic pressure (PASP) value.
Patients and methods
Patient selection
This was a retrospective study of 210 patients diagnosed
with acute PE confirmed by CTPA examination from June
2013 to December 2015. After the screening, 113 patients
were finally enrolled in our study (Fig.1).
13
Inclusion criteria
1. Acute PE confirmed by CTPA examination
2. Age18 years
Exclusion criteria
1. Definitive diagnosis of cor pulmonale
2. Malignant tumour
3. Chronic pulmonary embolism
4. Chronic heart failure
5. Pregnancy
6. Acute coronary syndrome
7. Reperfusion treatment between CTPA and
echocardiography
8. Either CTPA or echocardiograph was absent
CTPA acquisition
CTPA was performed using a 64-detector-row scanner
(AquilionKV-120; Toshiba Medical Systems Corporation,
Tokyo, Japan) with the following scanning parameters:
380mAs, 120kV, 5mm reconstruction interval, and 5mm
reconstruction section thickness. The scanning range of
CTPA was set from the thoracic inlet to the upper abdomen.
A bolus of 100ml of iodinated nonionic contrast medium
was injected by catheter into the antecubital vein at a rate
of 4ml/s using an automatic dual-tube high pressure injec-
tor (Ulrich REF XD 2051; Ulrich Medical GmbH, Ulm,
Germany).
We measured parameters including right ventricular
diameter (RVD), left ventricular diameter (LVD), main pul-
monary artery diameter (MPAD), ascending aorta diameter
(AOD), coronary sinus diameter (CSD), and superior vena
cava diameter (SVCD) using a CT-Sensation64 (v5.5.51116,
Neusoft, Shenyang, China).
RVDaxial,LVDaxial and RVDaxial/LVDaxial ratio
RVDaxial was measured by short axis in the axial plane
which was measured from the endocardial margin of the
RV free wall to the interventricular septum (Fig. 2a). The
same measurement method as RVDaxial was used to measure
LVDaxial at the same level (Fig.2b). The RVDaxial/LVDaxial
ratio was calculated. The measurement method was accord-
ing to Aribas et al. [12].
RVDfourchamber (RVD4CH), LVDfourchamber (LVD4CH) and
RVD4CH/LVD4CH ratio
RVD4CH was measured by level on the reconsgructed four-
chamber views at the maximal distance between the ven-
tricular endocardium and interventricular septum for right
Estimation of right ventricular dysfunction by computed tomography pulmonary angiography: a valuable 3

Fig. 1 The flow chart of case enrollment of our study according to the inclusive and exclusive criteria

ventricular and left ventricular according to the previous
study (Fig.2c, d) [13]. The ratio of RVD4CH/LVD4CH ratio
was calculated.
MPAD, AOD and MPAD/AOD ratio
The MPAD was measured perpendicular to the long axis,
from the inner wall to the other inner wall at the widest
diameter at the level of the pulmonary artery bifurcation.
The AOD was measured at the same slice using the same
method. The ratio of MPAD and AOD was then calculated.
to the long axis. The measurement method was according to
Cok et al. [8].
CSD
CSD was measured in its axial plane, proximal to its open-
ing at the level of the right margin of the interventricular
septum. The measurement of CSD was according to Gursel
et al. [14].
Deviation of the interventricular septum

SVCD Deviation of the interventricular septum was evaluated as

follow: If the interventricular septum was convex toward the
SVCD was transversely measured at the level of its conflu- RV, we identified the deviation of the interventricular sep-
ence from the inner wall to the other inner wall with respect tum (); If the interventricular septum was convex toward

13
4 D. Jia et al.

Fig. 2 Computed Tomogra-

phy Signs of RV Dysfunc-
tion in a 55-Year-old man. a
Right ventricular diameter by
short axis in the axial plane
(RVDaxial=52.86 mm). b Left
ventricular diameter by short
axis in the axial plane
(LVFaxial=33.98 mm)
(RVDaxial/LVDaxial ratio=1.56).
c Right ventricular
diameter in 4-charmber
(RVD4CH=50.87 mm).
d Left ventricular diameter in
4-charmber; (LVD4CH=
32.66mm) (RVD4CH/LVD4CH
radio=1.56). e A 4-chamber
(4-CH) view reconstruction by
CTPA shows interventricular
septum deviation (arrows).
f An interior vena cava reflux
(arrows)

the LV or flattened septum we identified the deviation of
the interventricular septum (+) (Fig.2e). The measurement
method was referred to the Kang et al. [13].
Inferior vena cava reflux
If there was no reflux into inferior vena cava (IVC) we
identified the IVC reflux (); otherwise, we identified IVC
reflux (+) (Fig.2f). The measurement method was referred
to the Aviram et al [15].
Echocardiography and grouping
We obtained the echocardiographic (ECHO) parameters
of the enrolled patients. All the echocardiography was
performed using an IE Elite ultrasound machine (Philips)
equipped with an S 51 transducer (frequency conversion
15MHz) and by an experienced ultrasound specialist.
Right ventricular dysfunction defined by ECHO met the fol-
lowing conditions: RV dilation, an increased RV-LV diam-
eter ratio (>0.9), hypokinesia of the free RV wall, increased
velocity of the jet of tricuspid regurgitation, decreased
tricuspid annulus plane systolic excursion, or combina-
tions [16, 17]. We used the standard above when evaluat-
ing enrolled PE patients for right ventricular dysfunction.
If right ventricular dysfunction was present, we defined the
patients as right ventricular dysfunction (+), allocated them
into group A, and recorded the PASP value; otherwise, they
were defined as right ventricular dysfunction () and allo-
cated into group B.

13
Estimation of right ventricular dysfunction by computed tomography pulmonary angiography: a valuable 5

Statistical analysis Table 1 Comparison of parameters between group A and group B

Group A Group B (n=71) p value
Statistical analysis was performed using a personal com- (n=42)
puter with SPSS version 22 (Chicago, IL, USA). Continuous
Age (year) 59.0711.88 54.98.2416.46 0.007
data are expressed as the meanstandard deviation (SD).
The t-test was used to evaluate the difference of continuous Gander (male/female) 20/22 39/32 0.578
data. The 2 test was used to evaluate differences in quali- RVDaxial (mm) 46.045.85 35.527.49 0.062
tative data. To analyse the relationship between right ven- LVDaxial (mm) 35.405.84 41.216.29 0.364
tricular dysfunction and the observed parameters measured RVDaxial/LVDaxial ratio 1.330.26 0.880.25 0.302
by CTPA, a logistic regression analysis model was used to RVD4CH (mm) 44.987.48 36.697.65 0.975
select the parameter in which a forward conditional method LVD4CH (mm) 38.317.69 42.766.53 0.102
was used for determining the goodness of fit. The area under RVD4CH/LVD4CH ratio 1.230.39 0.870.23 0.001
the ROC curve was used to confirm the optimal cut-off value, AOD (mm) 32.794.32 31.044.76 0.225
and the best sensitivity to specificity ratios were calculated. MPAD (mm) 32.194.77 27.485.25 0.735
Spearmans rank correlative analysis was used to analyse the MPAD/AOD ratio 0.990.18 0.890.15 0.820
correlation between PASP and the observed parameters in CSD (mm) 8.542.18 7.332.18 0.827
group A. A p value <0.05 was considered to indicate a sig- SCVD (mm) 18.413.11 17.414.03 0.072
nificant difference in all statistical analyses.

ROC curve of the RVDaxial/LVDaxial ratio and

Results RVD4CH/LVD4CH ratio from CTPA in the prediction
of right ventricular dysfunction
Demographics and baseline characteristics of the
patients ROC curve analysis revealed that the area under the curve
for the RVDaxial/LVDaxial ratio was 0.888 (95% CI: 0.818
After an initial screening, 113 acute PE patients were 0.958, p<0.0001) (Fig.3) and 0.801 for RVD4CH/LVD4CH
enrolled in our study (Fig.1). All the demographic and ratio (95% CI 0.7220.898, p<0.0001) (Fig. 4). The opti-
measurement parameters characterized were summarized as mum cut-off value for the prediction of the RVDaxial/LVDaxial
meanstandard deviation and male/female ratio (Table1). ratio was 1.02 (sensitivity 90.2%, specificity 88.7%) and
Forty-two patients showed right ventricular dysfunction was 0.999 for RVD4CH/LVD4CH ratio (sensitivity 71.4%,
(37.2%), and 71 patients did not show right ventricular specificity 88.7%).
dysfunction (62.8%). The average age of group A was
59.0711.88years and was 55.2416.14years for group Correlation of characteristics of CTPA with PASP of
B. There were 20 males and 22 females in group A and 39 ECHO
males and 32 females in group B (Table1).
Spearmans correlative analysis revealed that there was a
Comparison of characteristics of CTPA between group positive correlation between PASP and the MPAD/AOD
A and group B ratio (r=0.408, p=0.01), and there was no significant dif-
ference between PASP and the other observed parameters
The averge age and RVD4CH/LVD4CH ratio of group A (Table3).
was significantly higher than that of group B. The other dif-
ferences of demographic and measurement parameters were
not significant between group A and group B (Table1).
Table 2 Results of logistic regression analysis model
Correlation between observed parameters and right
ventricular dysfunction Beta OR p value 95.0% CI
Lower Upper
Logistic regression analysis showed that interventricular
septum deviation and RVDaxial/LVDaxial ratio ratio were cor- MPAD 0.139 1.149 0.057 0.996 1.326
related to right ventricular dysfunction with statistical sig- RVDaxial/LVDaxial ratio 3.393 29.764 0.003 3.173 279.210
nificance (p=0.001 and 0.03 respectively), and there were CSD 0.259 1.296 0.058 0.991 1.695
no statistically significant differences in the other param- Interventricular septum 2.046 7.739 0.001 2.232 26.834
deviation
eters (Table2).

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6 D. Jia et al.

Discussion

Rapid diagnosis and severity stratification is crucial for the

treatment of acute PE. If an examination could not only
diagnose the acute PE but also be used for severity strati-
fication or prediction, it would be beneficial for evaluation
of acute PE. CTPA may be such a useful examination that
satisfies the requirements of diagnosis and stratification for
acute PE [18]. In our study, interventricular septum devia-
tion and RVDaxial/LVDaxial ratio were correlated strongly to
right ventricular dysfunction evaluated by EHCO in acute
PE patients. Emergency department physicians could utilize
the interventricular septum deviation and RVDaxial/LVDaxial
ratio to predict right ventricular dysfunction once the diag-
nosis of PE was confirmed. ROC curve analysis revealed
that the optimal cut-off value of RVDaxial/LVDaxial ratio was
1.02 and was 0.999 for RVD4CH/LVD4CH ratio. Spear-
mans rank correlative analysis between the observed
parameter and PASP in group A showed that only the
MPAD/AOD ratio was positively correlated with PASP and
that the greater the MPAD/AOD ratio, the greater the PASP.
So the MPAD/AOD ratio can be used in preliminary predic-
tion of the severity of right ventricular dysfunction.
The RVDaxial/LVDaxial ratio was the most common indi-
cator measured by CTPA that predicted right ventricular
dysfunction. Some retrospective studies [19, 20], reported
that an RVD/LVD ratio >1.0 was an independent risk fac-
tor for right ventricular dysfunction. The RVDaxial/LVDaxial
ratio could be utilized for predicting 30-day mortality in
Fig. 3ROC curve with calculated area under the curve and optimal
cut-off point for RVDaxial/LVDaxial ratio predicting right ventricular
dysfunction: Optimal cut-off point is 1.02 (sensitivity 90.2%, speci-
ficity 88.7%). AUC is calculated at 0.888 (95% CI 0.8180.958,
p<0.0001)
Fig. 4ROC curve with calculated area under the curve and optimal
cut-off point for RVD4CH/LVD4CH ratio predicting right ventricu-
lar dysfunction: Optimal cut-off point is 0.999 (sensitivity 71.4%,
specificity 88.7%). AUC is calculated at 0.888 (95% CI 0.7140.887,
p<0.0001)
patients with acute pulmonary embolism [21]. Once the clot
flowed to the pulmonary artery, the resistance immediately
increases, and the RV afterload correspondingly increases. If
its compensatory capacity limit is exceeded, the RV muscle
must enlarge its dimensions to adapt to the increasing after-
load because of its thinner wall, compared to the left ven-
tricle. This RV dilation for compensatory pressure change
occurs in just a few minutes [22]. If the RV fails to adapt
to the afterload due to too much pressure, the back-flow
of blood to the left ventricle would be obviously reduced.
The circulation would congest, and the blood-flow of the
coronary arteries would also reduce. All factors mentioned
above can lead to circulation collapse, shock, and death in
acute PE patients [22].
RVD4CH/LVD4CH ratio was another common indica-
tor currently measured by CTPA with different measure-
ment method comparing with RVDaxial/LVDaxial ratio.
Kang et al. [13] utilized both RVD4CH/LVD4CH ratio and
RVDaxial/LVDaxial ratio for predicting the right ventricular
dysfunction and concluded that the correlation coefficient
for RVD4CH/LVD4CH ratio was slightly lower compared
with RVDaxial/LVDaxial ratio which were similar with our
study.
The interventricular septum bows toward the RV nor-
mally, but it may shift toward to LV due to the increased pres-
sure caused by sever pulmonary artery embolism [13, 23].
The interventricular septum deviation is a direct response to
the increased pressure in RV. In our study interventricular

13
Estimation of right ventricular dysfunction by computed tomography pulmonary angiography: a valuable 7

Table 3 Spearman correlative analysis between observed parameters of right ventricular dysfunction, but is positively correlated
and PASP value in group A with PASP.
Parameter r p value Our study has several limitations. The strength of the
conclusions is limited due to the retrospective research
Age (year) 0.038 0.812
design. The small sample size further limits the results of
MPAD (mm) 0.413 0.07 our study. Whether the enrolled patients received other
AOD (mm) 0.09 0.568 treatments, except anticoagulants and thrombolytics, may
SVCD (mm) 0.108 0.495 also have influenced our results. Finally, the cross-sectional
CSD (mm) 0.164 0.307 study design and being unable to follow-up on the short-
RVDaxial (mm) 0.273 0.08 term and long-term mortality of the patients also limited our
LVDaxial (mm) 0.212 0.178 study.
RVDaxial/LVDaxial ratio 0.287 0.065
RVD4CH 0.240 0.126
LVD4CH 0.218 0.165 Conclusions
RVD4CH/LVD4CH ratio 0.263 0.093
MPAD/AOD ratio 0.408 0.010 Once PE is confirmed by CTPA, the measurement of the
interventricular septum deviation, RVDaxial/LVDaxial ratio,
and the MPAD/AOD ratio by using quantitative analysis
septum deviation was another indicator correlated with of CTPA are valuable adjuncts for the prediction of right
right ventricular dysfunction with statistical significance. It ventricular dysfunction and the evaluation of the severity
can be utilized for predicting right ventricular dysfunction of acute PE.
in acute PE. IVC reflux is another indicator for increased
Compliance with ethical standards
RV pressure for various diseases. Kang et al. also reported
the efficacy for predicting the right ventricular dysfunction Conflict of interest The authors declare that no conflict of interest
[13], The different evaluation and statistical method of IVC exists.
reflux may cause the different opposite results. The purpose
of our study was that finding out a timesaving effective and
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