Pulmonary embolism echocardiography
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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] The presence of right ventricular dysfunction is a predictor of early death among patients with PE.[3]
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. The presence of right ventricular dysfunction is a predictor of early death among patients with PE.[3]
- Echocardiography findings that are indicative of right ventricular dysfunction are mainly:[4][5]
- 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]
- Paradoxical intraventricular septal motio#n
- Tricuspid regurgitation
- Pulmonary artery hypertension (systolic pulmonary artery pressure over 30 mmHg)
- 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.[6]
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.
- 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%).[7]
- 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.[8][9]
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.
- ↑ 3.0 3.1 Goldhaber SZ, Visani L, De Rosa M (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218.
- ↑ 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.
- ↑ 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)