Role of echocardiography in the diagnosis and treatment of acute pulmonary thromboembolism

Echocardiographic findings in patients with acute pulmonary embolism at Sohag University Hospitals

Background

Acute pulmonary thromboembolism (PTE) is one of the serious medical issues with higher prevalence and mortality rates. As mentioned in several medical reports, most of the chest pain patients, visiting the emergency departments, are usually diagnosed with either acute PTE, acute coronary syndromes, or acute aortic syndromes. The current study aimed to study the risk factors and explore the echocardiographic findings in patients with PTE.

Results

Forty patients with acute pulmonary embolism were enrolled in the study. Echocardiography and computed tomography pulmonary angiography (CTPA) were evaluated for all participants. The echocardiography showed that 29 patients (72.5%) had echocardiographic findings suggestive of acute PTE. Twenty-four patients (60%) had tricuspid regurge. Twenty-one patients (52.5%) had dilated right ventricle (RV). Also, 13 patients (32.5%) had an echocardiographic finding of pulmonary hypertension. Furthermore, ten patients (25%) had McConnell’s sign, and 21 patients (52.5%) had RV systolic dysfunction where only two (5%) showed RV thrombosis. Echocardiographic data of the eight high-risk patients showed that 6 patients (75%) had TR, 8 patients (100%) had dilated RV, 5 patients (62.5%) had pulmonary hypertension, 8 patients (100%) had McConnell’s sign, one patient (12.5%) had RV thrombus, and 8 patients (100%) had RV systolic dysfunction.

Conclusion

The results revealed that thrombus in the main pulmonary trunk was a high-risk factor for patients with acute pulmonary embolism. The current study suggested that echocardiography is an important bedside imaging tool for the diagnosis of PTE. Echocardiography could detect the tricuspid regurge, pulmonary hypertension, McConnell’s sign, RV dilatation, thrombosis, and dysfunction. Furthermore, echocardiography was considered a non-invasive test for rapid diagnosis of PTE and determining the degree of the risk category (high- or low-risk patients) specially with the presence of McConnell’s sign, dilated RV, and RV systolic dysfunction.

Early bilateral pulmonary embolism following a moderate blunt chest trauma: A case report

Post-traumatic pulmonary embolism (PE) remains a major problem in cardio-pulmonary diseases and represent the third most common cause of death in trauma patients. Traditional PE occur most commonly between the fifth and the seventh day after a major trauma and are rare before the fourth day. Here, we report a case of acute pulmonary embolism developing 1 day after a moderate thoracic injury in a previously well young man. The diagnosis was made by non-invasive methods and the patient was given anticoagulation therapy with good outcome. The circumstances and the early occurrence of PE in this case is at odds with what is generally reported after trauma.

A Floating Right Atrial and Ventricular Thrombus in a Patient with Syncope

Here, we describe a rare echocardiographic finding of a floating right heart thrombus in an elderly woman who presented with an unexplained syncope. Our case demonstrates the pivotal role of echocardiography in the workup of patients admitted with syncope.

Pulmonary Embolism: A Practical Guide for the Busy Clinician

Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.

Dramatic Normalization of the Echocardiographic Pulmonary-to-Left Atrial Ratio with Thrombolysis in a Case of Life-Threatening Submassive Pulmonary Emboli

•A 74 year old male presented with bilateral submassive pulmonary emboli with moderately severe pulmonary hypertension with right ventricular systolic pressure (RVSP) 63 mm Hg. •Echocardiographic pulmonary-to-left atrial ratio (ePLAR) markedly elevated at 0.78 m/s (normal range for age 0.30 ± 0.09 m/s) suggesting significantly elevated transpulmonary gradient. •Thrombolysis almost fully resolved symptomatic embolic burden and normalized right ventricular function. RVSP 37 mm Hg, ePLAR 0.32 m/s. •One month after lysis, RVSP 26 mm Hg, ePLAR 0.22 m/s, now within the normal range for age.

Echocardiographic Evaluation of the Right Heart

The appropriate use of echocardiography may reduce the need for invasive diagnostic cardiac procedures. The right side of the heart has recently gained interest among cardiologists as it became clear that abnormalities of the right heart morphology and function are associated with increased morbidity and mortality. Echocardiography is easy to perform, relatively cheap, readily available and do not pose the risk of ionizing radiation. Conventional 2D and, more recently, 3D echocardiography provides pertinent anatomic and physiologic information about the right side of the heart. Because of the advantages and simplicity of echocardiography it continues to be an excellent tool for evaluating the structure and function of the right side of the heart. This review outlines the uses of echocardiography in evaluating the right heart structure and function.

Echocardiographic Diagnosis of Acute Pulmonary Embolism in Patients with McConnell's Sign

BACKGROUND

"McConnell's sign" (McCS), described as hypo- or akinesis of the right ventricular (RV) free wall with preservation of the apex, is associated with acute pulmonary embolism (aPE). However, the sensitivity of McCS for the detection of aPE is limited. We sought to evaluate in patients with McCS, whether echocardiographic parameters of global and regional RV function could differentiate between patients with and without aPE.

METHODS

We reviewed echocardiograms of 81 patients with McCS, who underwent CT or V/Q studies for suspected PE, and 40 normal controls (NL). Echocardiograms were analyzed to measure pulmonary artery systolic pressure (PASP), tricuspid regurgitation (TR) by vena contracta width, conventional indices of RV function, and speckle tracking-derived longitudinal free wall strain. ROC analysis was performed to evaluate the diagnostic accuracy of these parameters for diagnosis of aPE.

RESULTS

Fifty-five of eighty-one (68%) had PE (McCS + PE), while 26 of 81 (32%) did not (McCS - PE). Compared to NL, global and segmental RV strain were lower in patients with McCS, contrary to the notion of normal apical function. In McCS + PE, compared to McCS - PE: (1) PASP, fractional area change and TR were significantly lower; (2) strain magnitude was significantly lower globally and in basal and apical segments. Individual parameters had similar diagnostic accuracy by ROC analysis, which further improved by combining parameters. In McCS - PE, 69% of patients had pulmonary hypertension (PH).

CONCLUSIONS

McCS and aPE are not synonymous. RV free wall strain may aid in differential diagnosis of patients with McCS evaluated for aPE. Specifically, McCS should prompt an inquiry for evidence of PH, which would indicate that aPE is less likely.

Extracorporeal cardiopulmonary resuscitation in bedside echocardiography-diagnosed massive pulmonary embolism

Acute pulmonary embolism (PE) is one of the major causes of inhospital cardiac arrest as well as out-of-hospital cardiac arrest. Bedside diagnosis of acute PE in the emergency department (ED) can be challenging, especially in a cardiac arrest setting. Even if the early diagnosis of an acute massive PE had been made, hemodynamic instability may be worsened unless obstructive shock gets resolved. We present a case of a 46-year-old woman who developed pulseless electrical activity (PEA) after complaining of weakness and dyspnea in an ambulance, presumptively diagnosed as acute PE by bedside focused echocardiography. She received thrombolytic therapy and was rescued by extracorporeal cardiopulmonary resuscitation for recurrent PEA arrest in the ED. Focused bedside echocardiography provides a rapid diagnostic adjunct, and extracorporeal cardiopulmonary resuscitation can be a valuable rescue therapy for PEA arrest from massive PE.

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

Evaluation of right ventricular systolic function by the analysis of tricuspid annular motion in patients with acute pulmonary embolism

Background

Measurement of right ventricular (RV) systolic function is important for patients with acute pulmonary embolism (PE). However, assessment of RV function is a challenge due to its complex anatomy. We measured RV systolic function with analysis of tricuspid annular motion in acute PE patients.

Methods

From August 2007 to May 2011, all consecutive PE patients were prospectively included. Tricuspid annular motion was analyzed with tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TASV).

Results

We analyzed total 50 patients (38 females, 68 ± 14 years). Mean RV fractional area change (RVFAC) was 26.2 ± 10.8%; RV Tei index 0.78 ± 0.35; TR Vmax 3.8 ± 0.5 m/sec; pulmonary vascular resistance (PVR) 3.5 ± 1.2 WU. TAPSE was 16 ± 4 mm and TASV was 11.7 ± 4.0 cm/sec. TAPSE showed significant correlations with RVFAC (r = 0.841, p < 0.001), RV Tei index (r = -0.347, p = 0.018), Log B-type natriuretic peptide (BNP) (r = -0.634, p < 0.001) and PVR (r = -0.635, p < 0.001). TASV also revealed significant correlations with RVFAC (r = 0.605, p < 0.001), RV Tei index (r = -0.380, p = 0.009), LogBNP (r = -0.477, p = 0.001) and PVR (r = -0.483, p = 0.001). The best cutoff of TAPSE for detection of RV systolic dysfunction (defined as RVFAC < 35%) was 1.75 cm [Areas under the curve (AUC) = 0.96, p < 0.001] with a sensitivity of 87% and specificity 91%. The best cutoff for TASV was 13.8 cm/sec (AUC = 0.90, p < 0.001), sensitivity 86% and specificity 78%. However, there was no statistical significance in the detection of RV dysfunction (difference = 0.07, 95% CI = -0.21-0.17, p = 0.130) between TAPSE and TASV.

Conclusion

TAPSE and TASV showed significant correlations with conventional echocardiographic parameters of RV function and LogBNP value. These values can be used to detect RV systolic dysfunction more easily in patients with acute PE.

Usefulness of emergency ultrasound in nontraumatic cardiac arrest

Treatment of nontraumatic cardiac arrest in the hospital setting depends on the recognition of heart rhythm and differential diagnosis of the underlying condition while maintaining a constant oxygenated blood flow by ventilation and chest compression. Diagnostic process relies only on patient's history, physical findings, and active electrocardiography. Ultrasound is not currently scheduled in the resuscitation guidelines. Nevertheless, the use of real-time ultrasonography during resuscitation has the potential to improve diagnostic accuracy and allows the physician a greater confidence in deciding aggressive life-saving therapeutic procedures. This article reviews the current opinions and literature about the use of emergency ultrasound during resuscitation of nontraumatic cardiac arrest. Cardiac and lung ultrasound have a great potential in identifying the reversible mechanical causes of pulseless electrical activity or asystole. Brief examination of the heart can even detect a real cardiac standstill regardless of electrical activity displayed on the monitor, which is a crucial prognostic indicator. Moreover, ultrasound can be useful to verify and monitor the tracheal tube placement. Limitation to the use of ultrasound is the need to minimize the no-flow intervals during mechanical cardiopulmonary resuscitation. However, real-time ultrasound can be successfully applied during brief pausing of chest compression and first pulse-check. Finally, lung sonographic examination targeted to the detection of signs of pulmonary congestion has the potential to allow hemodynamic noninvasive monitoring before and after mechanical cardiopulmonary maneuvers.

Critical appraisal on the utility of echocardiography in the management of acute pulmonary embolism

Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.

[Echocardiography in the Intensive Care Unit]

The echocardiography can provide important and relevant information and the critically ill patient presents a challenge for the echocardiographer: from limitations in image acquisition to interpretation in the context of rapid physiological and intervention changes. The most frequent reason for requesting an echocardiogram in the ICU is probably to assess left ventricular function. In any case, information of direct relevance for clinical management can in relationship to abnormalities of structure and function can be obtained and used to estimate pulmonary arterial and venous pressures. It can help to investigate the consequences of myocardial ischemia, valvular dysfunction and pericardial disease and detect changes characteristic of specific conditions (e.g. sepsis, pulmonary thromboembolism), although this must be interpreted in the context of each individual patient. The echocardiography also can be used to monitor the therapeutic interventions. The applications of echocardiography in the critical care setting are reviewed, with special emphasis on the assessment of cardiac physiology.

Midventricular peak systolic strain and Tei index of the right ventricle correlated with decreased right ventricular systolic function in patients with acute pulmonary thromboembolism

BACKGROUND

Assessment of right ventricular (RV) systolic function remains difficult because of the RV's complex shape. We aimed to evaluate RV systolic function with strain analysis in patients with acute pulmonary thromboembolism (PTE).

PATIENTS AND METHODS

From March 2005 to June 2006, 28 consecutive patients with acute PTE were included in this study. After excluding four patients, three with recurrent episodes of PTE and one with permanent pacemaker, the remaining 24 patients (10 males, mean age 69.0+/-10 years) were analyzed.

RESULTS

Mean RV fractional area change (RVFAC) was 20.1+/-8.7%; RV Tei index was 0.86+/-0.23; tricuspid annular plane systolic excursion (TAPSE) was 1.56+/-0.31 cm; and TR Vmax was 3.6+/-0.4 m/s at the time of diagnosis. Midventricular peak systolic strain of RV was markedly decreased (base: -18.0+/-6.6%, midventricle: -5.4+/-12.8%, apex: -10.6+/-8.1%). After treatment, follow-up echocardiographic data were obtained from 20 patients (mean: 11.0+/-8.2 days, duration: 4-34 days). Mean RVFAC, RV Tei index, TAPSE and TR Vmax were significantly improved (P<0.001). Midventricular peak systolic strains of RV were also significantly improved (base: -20.9+/-7.0%, P=0.055, midventricle: -21.1+/-6.8%, P<0.001, apex: -12.7+/-8.1%, P=0.314). Midventricular peak systolic strain of RV showed significant negative correlation with RVFAC (r=-0.660, P<0.001) and TAPSE (r=-0.642, P<0.001). Also, the RV Tei index showed significant correlation with RVFAC (r=-0.646, P<0.001) and TAPSE (r=-0.647, P<0.001).

CONCLUSIONS

Midventricular peak systolic strain and RV Tei index decreased in the patients with acute PTE and improved after stabilization. These values can therefore be used to assess RV systolic function in patients with acute PTE.

C.A.U.S.E.: Cardiac arrest ultra-sound exam—A better approach to managing patients in primary non-arrhythmogenic cardiac arrest

Cardiac arrest is a condition frequently encountered by physicians in the hospital setting including the Emergency Department, Intensive Care Unit and medical/surgical wards. This paper reviews the current literature involving the use of ultrasound in resuscitation and proposes an algorithmic approach for the use of ultrasound during cardiac arrest. At present there is the need for a means of differentiating between various causes of cardiac arrest, which are not a direct result of a primary ventricular arrhythmia. Identifying the cause of pulseless electrical activity or asystole is important as the underlying cause is what guides management in such cases. This approach, incorporating ultrasound to manage cardiac arrest aids in the diagnosis of the most common and easily reversible causes of cardiac arrest not caused by primary ventricular arrhythmia, namely; severe hypovolemia, tension pneumothorax, cardiac tamponade, and massive pulmonary embolus. These four conditions are addressed in this paper using four accepted emergency ultrasound applications to be performed during resuscitation of a cardiac arrest patient with the aim of determining the underlying cause of a cardiac arrest. Identifying the underlying cause of cardiac arrest represents the one of the greatest challenges of managing patients with asystole or PEA and accurate determination has the potential to improve management by guiding therapeutic decisions. We include several clinical images demonstrating examples of cardiac tamponade, massive pulmonary embolus, and severe hypovolemia secondary to abdominal aortic aneurysm. In conclusion, this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.

Acute pulmonary embolism: an update on diagnosis and management

Pulmonary embolism (PE) is a common problem. Given the significant overlap of symptoms and signs between the presentation of PE and acute coronary syndromes, it becomes clear that cardiologists must be familiar with the diagnosis and treatment of PE. The critical issue is always to consider PE in the diagnosis of chest pain. It is then important to determine the likelihood of the diagnosis. For patients at moderate-to-high risk, helical CT provides a rapid and noninvasive diagnostic tool. Several other imaging studies are also available including ventilation/perfusion (V/Q) scan, magnetic resonance imaging, and pulmonary arteriography. Echocardiography can also provide valuable prognostic information. Several biomarkers including the d-dimers, troponins, and natriuretic peptides may provide additional information. The cornerstone of treatment includes anticoagulation. For patients with massive or submassive PE, thrombolysis and embolectomy should be considered. Finally, both primary and secondary prevention are critical to the long-term health of the patient.