Lack of functional information explains the poor performance of ‘clot load scores’ at predicting outcome in acute pulmonary embolism

•We model the response of individuals to pulmonary embolism including the spatial distribution of emboli.•Model predictions correlate well with indicators of right ventricular dysfunction in each patient.•The redistribution of blood from its normal pattern is represented in the model but not in current clinical clot load scores.•We also predict minimal impact of partial occlusion until a vessel is almost completely occluded.•We suggest that this effect needs to be included in clot load scoring to improve their usefulness as predictors of pulmonary embolism severity.

Clot load scores have previously been developed with the goal of improving prognosis in acute pulmonary embolism (PE). These scores provide a simple estimate of pulmonary vascular bed obstruction, however they have not been adopted clinically as they have poor correlation with mortality and right ventricular (RV) dysfunction. This study performed a quantitative analysis of blood flow and gas exchange in 12 patient-specific models of PE, to understand the limitations of current clot load scores and how their prognostic value could be improved. Prediction of hypoxemia in the models when using estimated baseline (non-occluded) minute ventilation and cardiac output correlated closely with clinical metrics for RV dysfunction, whereas the clot load score had only a weak correlation. The model predicts that large central clots have a greater impact on function than smaller distributed clots with the same total clot load, and that the partial occlusion of a vessel only has a significant impact on pulmonary function when the vessel is close to completely occluded. The effect of clot distribution on the redistribution of blood from its normal pattern – and hence the magnitude of the potential effect on gas exchange – is represented in the model but is not included in current clot load scores. Improved scoring systems need to account for the expected normal distribution of blood in the lung, and the impact of clot on redistributing the blood flow.