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

Perioperative echocardiographic strain analysis: what anesthesiologists should know

PURPOSE

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

CLINICAL FEATURES

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

CONCLUSION

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Echocardiographic Assessment of Patients with Pulmonary Tumor Thrombotic Microangiopathy First Diagnosed in the Emergency Department

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal disease that obstructs pulmonary vessels, leading to pulmonary hypertension (PH) and right-sided heart failure causing rapid progressive dyspnea in patients with cancer. This retrospective chart review involved nine patients with PTTM who were first clinically diagnosed in a tertiary emergency department (ED) between January 2015 and June 2021. They underwent laboratory tests, chest radiography, chest computed tomography (CT), and echocardiography. All patients presented with severe and rapidly progressive dyspnea within a few days, a high oxygen demand. The right ventricle (RV): left ventricle ratio was >1 on chest CT, and no life-threatening pulmonary thromboembolism (PTE) was observed. Echocardiographic findings indicated that all patients had moderate-to-severe RV dilatation with a D-shaped LV. The median tricuspid regurgitation maximum velocity was 3.8 m/s, and the median RV systolic pressure was 63 mmHg, indicating severe PH. The median value of tricuspid annular plane systolic excursion was 15 mm, showing a decrease in RV systolic function, and McConnell’s sign was observed in five patients. Two patients immediately underwent chemotherapy and are currently alive. PTTM should be suspected and evaluated using echocardiography in patients with cancer presenting to the ED with acute dyspnea and RV failure without PTE.

Evaluating the Right Ventricle in Acute and Chronic Pulmonary Embolism: Current and Future Considerations

The right ventricle (RV), due to its morphologic and physiologic differences, is susceptible to sudden increase in RV afterload, as noted in patients with acute pulmonary embolism (PE). Functional impairment of RV function is a stronger presage of adverse outcomes in acute PE than the location or burden of emboli. While current iterations of most clinical prognostic scores do not incorporate RV dysfunction, advancements in imaging have enabled more granular and accurate assessment of RV dysfunction in acute PE. RV enlargement and dysfunction on imaging is noted only in a subset of patients with acute PE and is dependent on underlying cardiopulmonary reserve and clot burden. Specific signs like McConnell's and "60/60" sign are noted in less than 20% of patients with acute PE. About 2% of patients with acute PE develop chronic thromboembolic pulmonary hypertension, characterized by continued deterioration in RV function in a subset of patients with a continuum of RV function from preserved to overt right heart failure. Advances in molecular and other imaging will help better characterize RV dysfunction in this population and evaluate the response to therapies.

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings

Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.

Myocardial strain analysis of the right ventricle: comparison of different cardiovascular magnetic resonance and echocardiographic techniques

BACKGROUND

Right ventricular (RV) strain is a useful predictor of prognosis in various cardiovascular diseases, including those traditionally believed to impact only the left ventricle. We aimed to determine inter-modality and inter-technique agreement in RV longitudinal strain (LS) measurements between currently available cardiovascular magnetic resonance (CMR) and echocardiographic techniques, as well as their reproducibility and the impact of layer-specific strain measurements.

METHODS

RV-LS was determined in 62 patients using 2D speckle tracking echocardiography (STE, Epsilon) and two CMR techniques: feature tracking (FT) and strain-encoding (SENC), and in 17 healthy subjects using FT and SENC only. Measurements included global and free-wall LS (GLS, FWLS). Inter-technique agreement was assessed using linear regression and Bland-Altman analysis. Reproducibility was quantified using intraclass correlation (ICC) and coefficients of variation (CoV).

RESULTS

We found similar moderate agreement between both CMR techniques and STE in patients: r = 0.57-0.63 for SENC; r = 0.50-0.62 for FT. The correlation between SENC and STE was better for GLS (r = 0.63) than for FWLS (r = 0.57). Conversely, the correlation between FT and STE was higher for FWLS (r = 0.60-0.62) than GLS (r = 0.50-0.54). FT-midmyocardial strain correlated better with SENC and STE than FT-subendocardial strain. The agreement between SENC and FT was fair (r = 0.36-0.41, bias: - 6.4 to - 10.4%) in the entire study group. All techniques except FT showed excellent reproducibility (ICC: 0.62-0.96, CoV: 0.04-0.30).

CONCLUSIONS

We found only moderate inter-modality agreement with STE in RV-LS for both FT and SENC and poor agreement when comparing between the CMR techniques. Different modalities and techniques should not be used interchangeably to determine and monitor RV strain.

Role of echocardiography in managing acute pulmonary embolism

The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.

Echocardiographic Predictors of Long-Term Mortality in Patients Presenting With Acute Pulmonary Embolism

Pulmonary embolism (PE) is associated with a high mortality; whether echocardiographic evaluation at presentation predicts long-term adverse outcomes is of importance. We sought to determine if a composite of routinely obtained echocardiographic parameters could determine long-term adverse events in PE patients. Right ventricular (RV) size and function and right atrial (RA) size were retrospectively evaluated in 233 consecutive PE patients with an inpatient echocardiogram, and compared with 70 healthy controls; mortality at 3 years was confirmed. PE patients had increased RV size (RV parasternal long-axis diameter [RVPLAX] and RV end-diastolic volume [p < 0.001 for both]) and RA area (p < 0.001). RV function was reduced in PE patients (RV fractional area change and RV ejection fraction [p <0.001 for both]). Peak tricuspid regurgitation (TR) velocity was higher in the PE group. At follow-up (3.0 ± 2.1 years), 61 patients died; multivariable analysis demonstrated RVPLAX diameter >37 mm (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.3 to 4.2; p = 0.005), RA area >20 cm² (HR 2.0, 95% CI 1.1 to 3.5; p = 0.016), and TR velocity >2.9 ms^-1 (HR 1.9, 95% CI 1.1 to 3.4; p = 0.021), were independent echocardiographic predictors of mortality. Patients with all 3 "risk markers" had ∼17-fold increased mortality compared with those with no "risk markers" (HR 16.9, 95% CI 6.1 to 47.2; p < 0.001). In conclusion, a composite of routinely collected echocardiographic parameters, namely an enlarged RA and RV (RVPLAX diameter), and TR velocity, were independent predictors of mortality in PE patients, with an exponential increase in mortality when all 3 parameters were significantly altered. Prospective validation is required to confirm these preliminary observations.

Resuscitative Cardiopulmonary Ultrasound and Transesophageal Echocardiography in the Emergency Department

Resuscitative ultrasound describes point-of-care applications that provide diagnostic information, physiologic monitoring, and procedural guidance in critically ill patients. This article reviews the evaluation of ventricular function, identification of pericardial effusion and tamponade, evaluation of preload and fluid responsiveness, and hemodynamic monitoring, as some of the main applications where this modality can help emergency physicians during resuscitation of critically ill patients.

Rapid evaluation of acute pulmonary embolism with thromboembolism-in-transit

We report a case of thromboembolism-in-transit through a patent foramen ovale that could cause systemic embolism in a patient with pulmonary embolism. An accurate and quick diagnosis by transthoracic echocardiography and computed tomography allowed emergent surgical thromboembolectomy to be performed without complications. Integral diagnostic workup should be performed in case of acute pulmonary thromboembolism whether the patient is hemodynamically stable or not.

Three-dimensional right-ventricular regional deformation and survival in pulmonary hypertension

Aims

Survival in pulmonary hypertension (PH) relates to right ventricular (RV) function. However, the RV unique anatomy and structure limit 2D analysis and its regional 3D function has not been studied yet. The aim of this study was to assess the implications of global and regional 3D RV deformation on clinical condition and survival in adults with PH and healthy controls.

Methods and results

We collected a prospective longitudinal cohort of 104 consecutive PH patients and 34 healthy controls between September 2014 and December 2015. Acquired 3D transthoracic RV echocardiographic sequences were analysed by semi-automatic software (TomTec 4D RV-Function 2.0). Output meshes were post-processed to extract regional motion and deformation. Global and regional statistics provided deformation patterns for each subgroup of subjects. RV lateral and inferior regions showed the highest deformation. In PH patients, RV global and regional motion and deformation [both circumferential, longitudinal, and area strain (AS)] were affected in all segments (P < 0.001 against healthy controls). Deformation patterns gradually worsened with the clinical condition. Over 6.7 [5.8-7.2] months follow-up, 16 (15.4%) patients died from cardio-pulmonary causes. Right atrial pressure, global RV AS, tricuspid annular plane systolic excursion, 3D RV ejection fraction, and end-diastolic volume were independent predictors of survival. Global RV AS  > -18% was the most powerful RV function parameter, identifying patients with a 48%-increased risk of death (AUC 0.83 [0.74-0.90], P < 0.001).

Conclusion

Right ventricular strain patterns gradually worsen in PH patients and provide independent prognostic information in this population.

Pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria

A 59-year-old woman presented with a sudden onset of breathlessness and chest pain. An echocardiography and CT scan showed pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria. For haemodynamically stable patients, the optimal management strategy is poorly defined. Three main strategies were considered: surgical thrombectomy, thrombolysis and anticoagulation. Surgery with reversal of anticoagulation may lead to further coagulation and increased risk of bleeding complications. The significant pulmonary hypertension and right ventricular infarction raised the prospect of difficult weaning from cardiopulmonary bypass following thrombectomy. Thrombolysis, which has significant mortality rate, and systemic embolisation including pulmonary infarction with haemorrhagic transformation were also contraindications. A multidisciplinary approach was adopted and anticoagulation was therefore believed to be the safest and effective approach. Here, the use of anticoagulation alone was fortunately successful but could as easily end in disaster. This approach should be considered the ideal paradigm to yield optimum outcomes.

A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion

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The authors report on PDS after pericardial drainage.

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PDS is rare and can manifest as LV, biventricular, or RV failure.

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Treatment is supportive, and recovery of ventricular function is expected in survivors.

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The mechanisms are unclear, although many have been proposed.

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Mortality is high, and PDS may occur even in small-volume pericardiocentesis.

Speckle tracking analysis in intensive care unit: A toy or a tool?

The use of conventional echocardiography in the intensive care unit (ICU) is today established to assess left and right ventricular systolic function, for preload determination and procedural guidance. Next step in ICU echocardiography could be the use of novel ultrasound techniques such as strain echocardiography to assist in the management of patients with acute coronary syndrome, heart failure, or pulmonary embolism. This review has gathered the available evidence supporting the incremental value of strain in the diagnostic workup of cardiac diseases treated in ICU.

Echocardiographic assessment of the right ventricle in the current era: Application in clinical practice

The right ventricle has unique structural and functional characteristics. It is now well recognized that the so-called forgotten ventricle is a key player in cardiovascular physiology. Furthermore, there is accumulating evidence that demonstrates right ventricular dysfunction as an important marker of morbidity and mortality in several commonly encountered clinical situations such as heart failure, pulmonary hypertension, pulmonary embolism, right ventricular myocardial infarction, and adult congenital heart disease. In contrast to the left ventricle, echocardiographic assessment of right ventricular function is more challenging as volume estimations are not possible without the use of three-dimensional (3D) echocardiography. Guidelines on chamber quantification provide a standardized approach to assessment of the right ventricle. The technique and limitations of each of the parameters for RV size and function need to be fully understood. In this era of multimodality imaging, echocardiography continues to remain a useful tool for the initial assessment and follow-up of patients with right heart pathology. Several novel approaches such as 3D and strain imaging of the right ventricle have expanded the usefulness of this indispensable modality.