Pulmonary embolism echocardiography: Difference between revisions
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==Echocardiography== | ==Echocardiography== | ||
In massive and submassive PE, right ventricular dysfunction seen on [[echocardiography]] may indicate that the [[pulmonary artery]] is severely obstructed and that the heart is unable to compensate. Some studies suggest that this finding may be an indication for [[thrombolysis]]. | In massive and submassive PE, [[right ventricular dysfunction]] seen on [[echocardiography]] may indicate that the [[pulmonary artery]] is severely obstructed and that the heart is unable to compensate. Some studies suggest that this finding may be an indication for [[thrombolysis]]. | ||
Echocardiography may show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The [[sensitivity]] and [[specificity]] of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.<ref>{{cite journal |author=McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT |title=Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=4 |pages=469-73 |year=1996 |pmid=8752195 |doi=}}</ref> | *[[Echocardiography]] findings that are indicative of [[right ventricular dysfunction]] are mainly:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref> | ||
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9) | |||
** [[RV]] systolic dysfunction | |||
* Other echocardiographic findings that are supportive of the presence of [[right ventricular dysfunction]] include:<ref name="pmid11992305">{{cite journal| author=Goldhaber SZ| title=Echocardiography in the management of pulmonary embolism. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 9 | pages= 691-700 | pmid=11992305 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11992305 }} </ref> | |||
** Abnormality in the motion of the [[interventricular septum]] | |||
** [[Tricuspid regurgitation]] | |||
** [[Pulmonary artery]] hypertension | |||
** [[Patent foramen ovale]] (might occur when the pressure in the [[right atria]] is higher than that in the [[left atrium]]) | |||
* Echocardiography may show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The [[sensitivity]] and [[specificity]] of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.<ref>{{cite journal |author=McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT |title=Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=4 |pages=469-73 |year=1996 |pmid=8752195 |doi=}}</ref> | |||
Shown below is an echocardiogram that demonstrates McConnell sign: | Shown below is an echocardiogram that demonstrates McConnell sign: | ||
Revision as of 17:58, 11 July 2014
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Routine echocardiography in patients with suspected pulmonary embolism (PE) is not required.[1] In fact, the majority of patients with PE have a normal echocardiography.[1] However if elevations in the cardiac troponins or brain natriuretic peptide are present, then acute right ventricular dysfunction may be present and echocardiography is warranted.[2] Echocardiography is valuable for the risk stratification of PE among hemodynamically unstable patients.[1]
Echocardiography
In massive and submassive PE, right ventricular dysfunction seen on echocardiography may indicate that the pulmonary artery is severely obstructed and that the heart is unable to compensate. Some studies suggest that this finding may be an indication for thrombolysis.
- Echocardiography findings that are indicative of right ventricular dysfunction are mainly:[3][4]
- RV dilation (ratio of apical 4-chamber RV diameter to left ventricle (LV) diameter > 0.9)
- RV systolic dysfunction
- Other echocardiographic findings that are supportive of the presence of right ventricular dysfunction include:[1]
- Abnormality in the motion of the interventricular septum
- Tricuspid regurgitation
- Pulmonary artery hypertension
- Patent foramen ovale (might occur when the pressure in the right atria is higher than that in the left atrium)
- Echocardiography may show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The sensitivity and specificity of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.[5]
Shown below is an echocardiogram that demonstrates McConnell sign: {{#ev:youtube|Tklaxe-kPrk}}
Echocardiography should be used to confirm the presence of right ventricular dysfunction if multidetector CT is not available.
The diagnosis of right ventricular dysfunction requires the presence of at least two of the following criteria in the absence of right ventricular hypertrophy:[6][7]
- Right-to-Left ventricular end diastolic diameter ratio>0.9 in the apical four-chamber view.
- Right-to-Left ventricular end diastolic diameter ratio>0.7 in the parasternal long-axis or subcostal four-chamber view.
- Paradoxical intraventricular septal motion
- Systolic pulmonary artery pressure over 30 mmHg.
In another study, a value of less than 1.0 for right-to-left ventricular diameter was shown to have a 100% negative predictive value for an uneventful outcome (95% CI: 94.3%, 100%).[8]
In addition to the above, echocardiography can also be useful in patients with right heart thromboemboli or with a patent foramen ovale. These patients have a higher rate of complications and a higher mortality rate.[9][10]
References
- ↑ 1.0 1.1 1.2 1.3 Goldhaber SZ (2002). "Echocardiography in the management of pulmonary embolism". Ann Intern Med. 136 (9): 691–700. PMID 11992305.
- ↑ Kucher N, Goldhaber SZ (2003). "Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism". Circulation. 108 (18): 2191–4. doi:10.1161/01.CIR.0000100687.99687.CE. PMID 14597581.
- ↑ Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
- ↑ Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter
|month=ignored (help) - ↑ McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). "Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism". Am. J. Cardiol. 78 (4): 469–73. PMID 8752195.
- ↑ Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G; et al. (2000). "Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction". Circulation. 101 (24): 2817–22. PMID 10859287.
- ↑ Sanchez O, Trinquart L, Caille V, Couturaud F, Pacouret G, Meneveau N; et al. (2010). "Prognostic factors for pulmonary embolism: the prep study, a prospective multicenter cohort study". Am J Respir Crit Care Med. 181 (2): 168–73. doi:10.1164/rccm.200906-0970OC. PMID 19910608.
- ↑ van der Meer RW, Pattynama PM, van Strijen MJ, van den Berg-Huijsmans AA, Hartmann IJ, Putter H; et al. (2005). "Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism". Radiology. 235 (3): 798–803. doi:10.1148/radiol.2353040593. PMID 15845793.
- ↑ Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H (1998). "Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism". Circulation. 97 (19): 1946–51. PMID 9609088. Retrieved 2011-12-21. Unknown parameter
|month=ignored (help) - ↑ "The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography". Eur. Heart J. 10 (12): 1046–59. 1989. PMID 2606115. Retrieved 2011-12-21. Unknown parameter
|month=ignored (help)