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Galit Aviram, MD; Assi Milwidsky, MD; Shlomo Berliner, MD, PhD; Yan Topilsky, MD; Tomer Ziv-Baran, PhD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

aDepartment of Radiology, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

bDepartment of Internal Medicine “E”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

cDepartment of Cardiology, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

dDepartment of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

CORRESPONDENCE TO: Galit Aviram, MD, Department of Radiology, Tel Aviv Sourasky Medical Center, Weitzman St, Tel Aviv 64239, Israel


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):254-255. doi:10.1016/j.chest.2016.04.025
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We thank Dr Yadlapati and colleagues for their interest in our article in which we described a new tool for risk assessment among 636 patients diagnosed as having pulmonary embolism (PE). The approach is based on a fully automatic volumetric analysis of all four cardiac chambers obtained from diagnostic nongated CT pulmonary angiography (CTPA), which revealed that a decreased left atrial (LA) volume is associated with higher ≤ 30-day mortality.

This is the largest series showing the significant value of reduced LA volume for predicting mortality among patients with PE and the only existing quantitative report on diagnostic CTPA scanning in this setting. Its main novelty is the concept of assessing LA volume rather than the traditionally used right ventricular dimensions for risk stratification in acute PE. Our cohort is composed mainly of whites; thus, the effect of race on chamber size is probably not significant. Because of the retrospective nature of this work, the measured cardiac volumes could not be adjusted for weight or body surface area (BSA). Moreover, routine CTPA is not cardiac-gated; thus, there is currently no validated way for adjusting the volumes to those parameters. However, the right to left atrial volume ratio was also associated with mortality, and it had a relatively similar discrimination ability. Since both atria are located in close proximity, they were scanned at approximately the same phase of the cardiac cycle, leading to a lesser effect of the phase variable and the patient’s BSA.

The presence of an LA volume ≤ 62 mL during the diagnosis of PE by CTPA emerged as the most statistically powerful discriminator of adverse prognosis. We agree that a numerical value of LA size cannot currently be used as a sole predictor of an adverse outcome in a specific patient and that it should be incorporated with other tools for risk stratification, such as hemodynamic status, comorbidities, and biomarker elevation. We also agree with Dr Yadlapati and colleagues that advancement in CT technology will soon allow performing CTPA that will be cardiac-gated, thus allowing further refining of the volumetric analysis tool by obtaining phase-specific volumes that can be corrected to the patient’s BSA. We strongly believe that the application of automatic volumetric assessments using more advanced cardiac-gated CTPA may allow the expediting of risk assessment and that large-scale prospective studies are required to evaluate the incremental discriminatory power of the new approach over the other risk stratification tools.

References

Yadlapati A. .Rich S. .Collins J. .Courtney D.M. .Schimmel D.R. . Prediction of mortality in pulmonary embolism based on left atrial volume measurements: Do indexed values matter? Chest. 2016;150:253-254 [PubMed]journal
 
Aviram G. .Soikher E. .Bendet A. .et al Prediction of mortality in pulmonary embolism based on left atrial volume measured on CT pulmonary angiography. Chest. 2016;149:667-675 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Yadlapati A. .Rich S. .Collins J. .Courtney D.M. .Schimmel D.R. . Prediction of mortality in pulmonary embolism based on left atrial volume measurements: Do indexed values matter? Chest. 2016;150:253-254 [PubMed]journal
 
Aviram G. .Soikher E. .Bendet A. .et al Prediction of mortality in pulmonary embolism based on left atrial volume measured on CT pulmonary angiography. Chest. 2016;149:667-675 [PubMed]journal. [CrossRef] [PubMed]
 
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