Echo Doppler predictors of pulmonary artery hypertension in patients with systemic sclerosis

Objectives: Evaluate echocardiographic predictors of pulmonary artery hypertension (PAH) in a prospective cohort of patients with systemic sclerosis (SSc). Methods: 38 patients with SSc who did not have PAH and significant left heart disease, with peak tricuspid regurgitant velocity (TRV) ≤ 2.8 m/sec and systolic pulmonary artery pressure (sPAP) < 40 mmHg on echo Doppler were enrolled. Patients underwent: clinical assessment, NT‐proBNP, and DLco measurements. Echo Doppler evaluation included right ventricular (RV) dimensions, tricuspid annular plan systolic excursion, fractional area change, tricuspid DTI systolic velocity, Tei index, pulmonary flow acceleration time (AcT), ratio of TRV to RV outflow tract time–velocity integral (TVI) and a parameter of disturbed RV ejection (TRV/AcT). After a planned 12‐month follow‐up we evaluated the predictive value of these parameters for the development of PAH, as demonstrated by right heart catheterization (RHC). Criteria for RHC were TRV ≥ 3 m/sec or sPAP ≥ 40 mmHg. Results: Four patients developed PAH. Only TRV/TVI and TRV/AcT ratios significantly predicted PAH development (TRV/TVI ratio ≥ 0.16 [predefined and ROC confirmed]: OR 99, CI 95%: 4.865–2015, P = 0.004; TRV/AcT ratio ≥ 0.022 [predefined and ROC confirmed]: OR 12.68, CI 95% 1.163–379.3, P = 0.036). Both parameters showed a good diagnostic power (TRV/TVI ratio: ROC area 79%, sensitivity 75%, specificity 97% and diagnostic accuracy 94.74% for cutoff value of 0.16; TRV/AcT ratio: ROC area 75%, sensitivity 75%, specificity 71% and diagnostic accuracy 72% for cutoff value of 0.022). Conclusions: This prospective study identified increased values of the two ratios TRV/TVI and TRV/AcT as predictors of PAH in SSc. (Echocardiography 2011;28:860‐869)     

超声心动图诊断急性肺动脉栓塞的价值

目的 :分析评价床旁超声心动图 (ECHO)在急性肺动脉栓塞 (APE)诊断中的实用价值。方法 :采用经胸ECHO对临床怀疑APE的 5 8例患者在 4～ 6h内行床旁ECHO检查。结果 :超声直接检出主肺动脉及左右肺动脉主干近端血栓者 4例 ,均被外科手术或肺动脉造影证实。本组具有典型右心负荷过重超声征象者 15例 (其中包括具有超声直接征象的 4例 ) ,核素肺灌注 通气扫描提示为双肺多发性大面积栓塞。仅右房、右室轻度增大或肺动脉轻度增宽者 19例 ,ECHO无改变者 2 4例 ,但核素肺灌注 通气扫描均提示为肺段或亚段栓塞。结论 :ECHO能够发现主肺动脉、左右肺动脉干内附壁血栓直接提示肺动脉栓塞 ,或根据右室负荷过重表现间接提示肺栓塞的可能 ,但对肺段或亚段栓塞者超声不能作出或排除诊断。     

Diagnostic value of transoesophageal echocardiography in suspected haemodynamically significant pulmonary embolism

OBJECTIVE—To assess the value of transoesophageal echocardiography (TOE) for diagnosing suspected haemodynamically significant pulmonary embolism and signs of right ventricular overload at standard echocardiography.
METHODS—113 consecutive patients (58 male; 55 female), mean (SD) age 53.6 (13.3) years, in whom there was clinical suspicion of pulmonary embolism and right ventricular overload on transthoracic echocardiography, underwent TOE in addition to routine diagnostic procedures to identify pulmonary artery thrombi.
RESULTS—TOE revealed thrombi in 32 of 51 patients who had suspected acute pulmonary embolism and in 31 of 62 with suspected chronic pulmonary embolism. In one patient a pulmonary angiosarcoma rather than chronic pulmonary embolism was found at surgery. The diagnosis of pulmonary embolism was confirmed in 77 patients by scintigraphy, spiral computed tomography, angiography, or necropsy (reference methods). While TOE failed to provide a diagnosis of pulmonary embolism in 15 of these 77 patients, no false positive findings were reported (sensitivity 80.5%, specificity 97.2%). In 11 and 26 cases, respectively, the thrombi were confined to the left or right pulmonary artery. Bilateral thrombi were found in 25 patients. Mobile thrombi were observed only in acute pulmonary embolism (in 19 of 32 patients). No complications of TOE were noted.
CONCLUSIONS—TOE permits visualisation of pulmonary arterial thrombi, confirming the diagnosis in the majority of patients with pulmonary embolism and right ventricular overload. This may be useful for prompt decision making in patients with haemodynamic compromise considered for thrombolysis or embolectomy.


Keywords: pulmonary embolism; transoesophageal echocardiography     

Silent Pulmonary Embolism of a Large Right Atrial Thrombus

We report the case of a patient who was admitted to the hospital with acute pulmonary embolism 2 weeks after a complicated pelvis fracture. Echocardiography revealed a large, long, and mobile thrombus in the right atrium. The patient was scheduled to undergo urgent surgical thrombectomy. Preoperative echocardiography did not detect any thrombi in the right heart and pulmonary artery. The obvious embolism of this large thrombus in the pulmonary circulation was silent as the patient remained asymptomatic and hemodynamically stable. We discuss the contribution of echocardiography to the appropriate therapeutic management of right atrial thrombi and particularly to the cancellation of urgent operative thrombectomy.     

QR in V1--an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism.

AIMS: To test the hypothesis that Qr in V(1)is a predictor of pulmonary embolism, right ventricular strain, and adverse clinical outcome. METHODS AND RESULTS: ECG's from 151 patients with suspected pulmonary embolism were blindly interpreted by two observers. Echocardiography, troponin I, and pro-brain natriuretic peptide levels were obtained in 75 patients with pulmonary embolism. Qr in V(1)(14 vs 0 in controls; p<0.0001) and ST elevation in V(1)> or =1 mV (15 vs 1 in controls; p=0.0002) were more frequently present in patients with pulmonary embolism. Sensitivity and specificity of Qr in V(1)and T wave inversion in V(2)for predicting right ventricular dysfunction were 31/97% and 45/94%, respectively. Three of five patients who died in-hospital and 11 of 20 patients with a complicated course, presented with Qr in V(1). After adjustment for right ventricular strain including ECG, echocardiography, pro-brain natriuretic peptide and troponin I levels, Qr in V(1)(OR 8.7, 95%CI 1.4-56.7; p=0.02) remained an independent predictor of adverse outcome. CONCLUSIONS: Among the ECG signs seen in patients with acute pulmonary embolism, Qr in V(1)is closely related to the presence of right ventricular dysfunction, and is an independent predictor of adverse clinical outcome.     

Echocardiographic Parameters and Brain Natriuretic Peptide in Patients after Surgical Repair of Tetralogy of Fallot

Background: Although the residual lesions after surgical correction of tetralogy of Fallot (TOF) can be evaluated by Doppler echocardiography (DE), the relation of DE parameters with the proBNP level, a potential biomarker of right ventricle overload, is not well known. The objective of this study was to evaluate the DE parameters and their relation to proBNP levels. Methods: proBNP plasma level and Doppler echocardiography parameters were obtained on the same day in 49 patients later after repair of TOF (mean age of 14.7 years, 51% female, mean PO time of 9.5 years). The DE parameters studied were the dimensions of the right atrium (RA) and ventricle (RV), RV diastolic and systolic function, and residual pulmonary lesions. The relation between them and proBNP levels were analyzed and the cutoff values of DE parameters for elevated proBNP determined. Results: proBNP was elevated in 53% and correlated with RV diastolic diameter (r = 0.41; P = 0.003), RA longitudinal (r = 0.52; P = 0.0001) and transversal (r = 0.47; P = 0.001) diameters, pressure half time of pulmonary regurgitation (PR) velocity (PHT) (r =?0.42; P = 0.005), and the PR index (r =?0.60; P < 0.001). By multivariate analysis, the PR index (r =?597; P = 0,001; CI: ?913.2 to ?280.8) and RA longitudinal (r = 7.74; P < 0,001; CI 4.18 to 11.31) were independent predictors of elevated proBNP. PHT lower than 64 msec (0.76) and PRi lower than 0.65 (0.81) had the best accuracy for elevated proBNP. Conclusion: proBNP may be increased in patients after surgical repair of TOF, correlated with the size of right cardiac chambers and the severity of PR. (Echocardiography 2010;27:442‐447)     

Should Transesophageal Echocardiography Become a Routine Test in Patients with Suspected Pulmonary Thromboembolism?

Pulmonary thromboembolism presents in two clinical subsets: acute pulmonary embolism (PE) with or without right heart thrombi or paradoxical embolism and chronic thromboembolic pulmonary hypertension (CTEPH). Both PE and CTEPH have been underdiagnosed and carry high mortality rates. Acute massive PE is a hemodynamic entity leading to right ventricular overload readily identified with the use of transthoracic echocardiography. Transesophageal echocardiography (TEE) is a noninvasive bedside technique that has high diagnostic accuracy for the detection of central pulmonary thromboembolism. Due to the high prevalence of central pulmonary thromboembolism in acute PE, TEE is a useful method to provide the necessary proof for the institution of thrombolytic therapy. In the subset of patients with acute PE combined with right heart thrombi or paradoxical embolism, TEE is the technique of choice to guide surgery. CTEPH presents as primary pulmonary hypertension, but it has become a surgically curable disease. TEE is a fast, fairly sensitive, and highly specific diagnostic bedside modality to select surgical candidates with CTEPH. TEE should become a routine test in patients with suspected massive acute PE, suspected right heart thrombi, or paradoxical embolism associated with acute pulmonary embolism and in patients with primary pulmonary hypertension to select those having CTEPH who are suitable for surgery.     

Transoesophageal echocardiography for definitive diagnosis of haemodynamically significant pulmonary embolism

Transoesophageal echocardiographic evaluation of right and leftpulmonary arteries, up to the origin of their lobar branches,was prospectively performed with a single plane probe in 32consecutive patients (18M, 14F, aged 55.5 ± 14.6, from32 to 80 years) with clinical or echocardiographic suspicionof pulmonary embolism, who met transthoracic echocardiographiccriteria of right ventricular overload Transoesophageal echocardiographyshowed unequivocal (20 patients) or suspected (three patients)intraluminar thrombi in 88.5% of 26 patients with haemodynamicallysignificant acute or chronic pulmonary embolism, confirmed withreference methods. The sensitivity of the unequivocal transoesophagealechocardiographic diagnosis was 80% for acute and 73% for chronichaemodynamically significant pulmonary embolism. No false-positiveresults were found (specificity 100%). Additionally, in three cases, transoesophageal echocardiographydisclosed the cause of the right ventricular overload revealinga previously undiagnosed atrial septal defect or Ebstein anomaly. Direct visualization of proximal pulmonary arterial thrombiby transoesophageal echocardiography emerges as a useful newmethod of prompt and definite diagnosis of haemodynamicallyimportant pulmonary embolism.     

Does a New Ultrasound Flow Modality Improve Visualization of Neonatal Pulmonary Veins?

Background: Blood flow imaging is a new ultrasound modality that supplements color Doppler imaging with angle‐independent information of flow direction that is not influenced by velocity aliasing. This is done by visualizing the blood speckle movement superimposed on the color Doppler images. This study aimed to investigate whether this method improves the visualization of the pulmonary veins in neonates. Methods: Twenty‐six neonates with suspected congenital heart disease were prospectively examined with echocardiography and blood flow imaging of the pulmonary veins after parental consent. For each patient, blood flow imaging and color Doppler imaging cine loops were presented to four observers (pediatric cardiologist/cardiologists) in a random order. Questions regarding the pulmonary venous connections and the overall quality of the pulmonary vein imaging were evaluated on a visual analogue scale from 0 (worst) to 100 (best). The methods were compared within each observer using the Wilcoxon's exact signed‐rank test. Results: Blood flow imaging (color Doppler imaging combined with the blood speckle movement) was consistently ranked as better than conventional color Doppler imaging for visualization of the pulmonary veins for all observers (all P‐values < 0.002). Conclusion: Blood flow imaging may improve the visualization of the pulmonary veins in neonates. (Echocardiography 2010;27:1113‐1119)     

Right atrial speckle tracking analysis as a novel noninvasive method for pulmonary hemodynamics assessment in patients with chronic systolic heart failure

Background: The right atrium (RA) plays multiple roles in the cardiac cycle. The reservoir phase of the RA is a dynamic rather than a static phase of cardiac cycle and RA deformation is dependent on pulmonary pressures exerted on the right ventricle and, therefore, backwards on the RA. The purpose of this study was to assess the accuracy and the clinical applicability of the speckle tracking echocardiography (STE) evaluation of the RA in predicting the invasive systolic pulmonary artery pressure (SPAP) in patients with systolic heart failure (HF) undergoing right heart catheterization (RHC). Methods: Thirty‐one hemodynamically stable, in‐clinic HF patients who were undergoing RHC were included. Doppler echocardiography and RHC catheterization were simultaneously performed. Echocardiographic measures and STE where obtained as peak atrial longitudinal strain (PALS), RA strain rate, and time to peak longitudinal strain (TPLS). RA PALS was inversely correlated with invasively assessed SPAP (r =–0.81; P < 0.001) while RA strain directly correlated with SPAP (r = 0.82; P < 0.001). RA PALS and strain rate retained this correlation even after nitroprusside challenge test (r =–0.81; P < 0.001 and r = 0.91; P < 0.001, respectively). Area under the curve optimal cutoffs for predicting the SPAP > 50 mmHg were for RA PALS 10.3% (AUC:0.93, sensitivity: 100%, specificity: 78%). Conclusion: RA STE showed a significant correlation with pulmonary pressure. RA assessment with STE can predict pulmonary artery hypertension in HF patients. This result is consistent with nitroprusside challenge test. Although RA STE is not routinely used, its evaluation may implement right heart evaluation in HF patients. (Echocardiography 2011;28:658‐664)     

Noninvasive Estimation of Pulmonary Vascular Resistance in Pulmonary Hypertension

Background: Determination of pulmonary vascular resistance (PVR) in patients with suspected or known pulmonary hypertension (PH) requires right heart catheterization. Our purpose was to use Doppler echocardiography to estimate PVR in patients with PH. Methods: Patient population consisted of 52 patients (53 ± 12 years; 35 females) who underwent Doppler echocardiography and right heart catheterization within 24 hours of each other. The ratio of peak tricuspid regurgitation velocity (TRV) and right ventricular outflow time-velocity integral (VTI_RVOT) was measured via transthoracic echocardiography and correlated to invasively determined PVR. A linear regression equation was generated to determine PVR by echocardiography based upon the TRV/VTI_RVOT ratio. PVR by echocardiography was compared to invasive PVR using Bland-Altman analysis. Results: Significant correlation was demonstrated between TRV/VTI_RVOT and PVR by catheterization (r = 0.73; P < 0.001). However, Bland-Altman analysis showed that agreement between PVR determined by echocardiography and invasive PVR was poor (bias = 0; standard deviation = 4.3 Wood units). In a subset of patients with invasive PVR < 8 Wood units (26 patients), correlation between TRV/VTI_RVOT and invasive PVR was strong (r = 0.94; P < 0.001). In these patients, agreement between PVR by echocardiography and invasive PVR was satisfactory (bias = 0; standard deviation = 0.5 Wood units). There was no correlation between TRV/VTI_RVOT and invasive PVR in patients with PVR > 8 Wood units (n = 26; r = 0.17). Conclusion: While TRV/VTI_RVOT correlates significantly with PVR, using it to estimate PVR in a PH patient population cannot be recommended.     

Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism.

OBJECTIVE: To investigate the prognostic value of echocardiographic findings in patients who present with symptoms suggestive of acute pulmonary embolism. DESIGN: 317 patients with clinically suspected pulmonary embolism were prospectively evaluated by echocardiography for the presence of right ventricular afterload stress and right heart or pulmonary artery thrombi. Objective confirmation of pulmonary embolism by lung scan or pulmonary angiography was obtained in 164 (52%). The presence of deep venous thrombosis was established in 90 of 158 patients (57%) who underwent phlebographic or Doppler sonographic studies. RESULTS: Right ventricular afterload stress was diagnosed in 87 patients (27%). Objective confirmation of pulmonary embolism and diagnosis of deep venous thrombosis was more common in patients with right ventricular afterload stress than in those without (83% v 40% and 46% v 22%, respectively; P < 0.001). This was also true for the detection of thrombi in the right heart and major pulmonary arteries (12 patients v 1 patient; P < 0.001) as well as for the in-hospital mortality from venous thromboembolism (13% v 0.9%; P < 0.001). One year mortality from pulmonary embolism was 13% in patients with right ventricular afterload stress at presentation compared with 1.3% in those without (P < 0.001). CONCLUSIONS: The presence of right ventricular afterload stress detected by echocardiography is a major determinant of short term prognosis in patients with clinically suspected acute pulmonary embolism.     

The role of transesophageal echocardiography in the management of patients with acute and chronic pulmonary thromboembolism

Acute and chronic pulmonary thromboembolism carry high mortality. The role of transesophageal echocardiography (TEE), however, has not been well delineated in patients with suspected pulmonary thromboembolism. The aim of the present study was to demonstrate the value of Tee in patients with various clinical manifestations of pulmonary thromboembolic disease. Twelve patients--ten males and two females, age 47-85 years--are presented in whom central pulmonary thromboembolism was found by TEE. Six patients were referred for breathlessness and had moderate to severe pulmonary hypertension (PH) with (3) or without (1) right atrial thrombus or had right heart dilatation (1) or right ventricular myxoma (1) on transthoracic echocardiography (TTE). Thrombolysis (2), surgery (2), and heparin (2) treatment was performed without angiography. All but one patient recovered. Six patients had severe PH by TTE, one of them had a right atrial thrombus. Angiography was done in five patients in whom surgery was considered. Pulmonary thromboendarterectomy was successfully performed in two patients, it was contraindicated in two patients for advanced age or severe left ventricular dysfunction, both patients died during follow-up, and two patients were waiting for surgery. In conclusion: TEE has a definite role in the management of patients with acute pulmonary thromboembolism or in pulmonary embolism associated with right-sided intracardiac masses and in the selection of patients with PH for pulmonary thromboendarterectomy.     

Echocardiographic characteristics of intravenous leiomyomatosis with intracardiac extension: a single-institution experience

Background: Intravenous leiomyomatosis (IVL) is a rare smooth‐muscle proliferation arising from a uterine myoma and occasionally extending into cardiac chambers. Methods and Results: A series of 10 consecutive patients with histologically and surgically proven intracardiac IVL between 2000 and 2010 in our hospital were reviewed. The echocardiographic features of 10 cases with IVL and extensive spread into the right‐sided cardiac chambers were described for the first time. All patients were female and the mean age was 42 ± 7 years old. The first symptoms of six patients (60%) were exertional dyspnea and palpitation of cardiac origin. Echocardiography showed that all the tumors originated from the inferior vena cava (IVC) and located in cardiac right chambers (70% in right atrium alone, 30% in right ventricle and atrium). Eight masses (80%) were oval, whereas the others (20%) were serpentine, all with well‐demarcated borders and most (70%) with heteroechogenic texture. Five tumors (50%) intermittently prolapsed into right ventricle through the tricuspid valve. Two patients with nodules adhering to the top of the tumors had pulmonary tumorous thromboembolism. Conclusion: Echocardiography is a simple and important technique to diagnose IVL with intracardiac extension. This disease should be considered in a female patient presenting with an extensive mass from IVC with well‐demarcated border in the right‐sided cardiac chambers. (Echocardiography 2011;28:934‐940)     

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy: Case report

Introduction:Air embolism has the potential to be serious and fatal. In this paper, we report 3 cases of air embolism associated with endoscopic medical procedures in which the patients were treated with hyperbaric oxygen immediately after diagnosis by transesophageal echocardiography. In addition, we systematically review the risk factors for air embolism, clinical presentation, treatment, and the importance of early hyperbaric oxygen therapy efficacy after recognition of air embolism.Patient Concerns:We present 3 patients with varying degrees of air embolism during endoscopic procedures, one of which was fatal, with large amounts of gas visible in the right and left heart chambers and pulmonary artery, 1 showing right heart enlargement with increased pulmonary artery pressure and tricuspid regurgitation, and 1 showing only a small amount of gas images in the heart chambers.Diagnoses:Based on E_TCO₂ and transesophageal echocardiography (TEE), diagnoses of air embolism were made.Interventions:The patients received symptomatic supportive therapy including CPR, 100% O₂ ventilation, cerebral protection, hyperbaric oxygen therapy and rehabilitation.Outcomes:Air embolism can causes respiratory, circulatory and neurological dysfunction. After aggressive treatment, one of the 3 patients died, 1 had permanent visual impairment, and 1 recovered completely without comorbidities.Conclusions:While it is common for small amounts of air/air bubbles to enter the circulatory system during endoscopic procedures, life-threatening air embolism is rare. Air embolism can lead to serious consequences, including respiratory, circulatory, and neurological impairment. Therefore, early recognition of severe air embolism and prompt hyperbaric oxygen therapy are essential to avoid its serious complications.     

Right ventricular thrombus and pulmonary emboli in a patient with emphysema: An echocardiographic and doppler documentation

Pulmonary hypertension is a known complication of chronic obstructive pulmonary disease (COPD). A worsening dyspnea in a patient with COPD is usually a sequela of the pulmonary disease. However, it may be due to pulmonary embolism, a complication which is difficult to diagnose in such patients. We present a patient with COPD in whom two-dimensional and Doppler echocardiography confirmed the diagnosis of pulmonary emboli by documenting right ventricular thrombus and pulmonary hypertension. This case report emphasizes the usefulness of these noninvasive cardiac imaging techniques in the detection and evaluation of pulmonary embolism in patients with COPD.     

The Role of Echocardiography Doppler in Pulmonary Embolism

The purpose of this review is to make a critical analysis of selected literature about the role of echo-Doppler in suspected or proved venous thromboembolism and to address some issues about the potential use of echo-Doppler in specific situations in patients with pulmonary embolism (PE). Echo-Doppler is of great value in patients with suspected PE because many conditions that may be clinically mistaken for PE will be diagnosed. Echo-Doppler should not be used alone to rule out the diagnosis of PE because the ability of the technique in proving the diagnosis of PE in a nonselected population is limited. Echo-Doppler may be of value for diagnosis in selected subgroups of PE patients, mostly in scenarios like the emergency department or intensive care unit. Echo-Doppler is valuable in the hemodynamic assessment of patients with PE, making possible a strategy for risk stratification of in-hospital death in relation to the degree of right ventricle dysfunction at the time of diagnosis of acute PE. Echo-Doppler is useful for serial assessment of patients with established diagnosis of chronic thromboembolic pulmonary hypertension. Echo-Doppler may be useful in follow-up of patients after a diagnosis of acute PE to enable early identification of patients with persistent pulmonary hypertension / right ventricle dysfunction.     

Differences in the duration of total ejection between right and left ventricles in chronic pulmonary hypertension

Background: Chronic pulmonary hypertension (cPH) is known to delay pulmonic valve closure resulting in a closely split second heart sound. We decided to measure total duration of right (RV) and left ventricular (LV) outflow tract (RVOT and LVOT) spectral signals using pulsed Doppler to determine if this approach was useful in identifying this narrowing in auscultation that should then result in a shorter temporal difference between the ejection of both ventricles. Methods: Standard measures of RV and LV performance as well as Doppler data was collected from 85 patients divided into two groups according to their estimated pulmonary artery systolic pressure obtained at the time of their echocardiographic examination. Difference in ejection between the ventricles was defined as the difference in ejection time between RVOT and LVOT, measured in milliseconds. Results: Chronic PH patients had a shorter total duration between RVOT and LVOT ejection time (–15 ± 16 ms vs. 22 ± 14 ms; P < 0.0001) than individuals without PH. This difference in total duration between RVOT and LVOT ejection not only showed a significant negative correlation with both PASP (r =–0.65; P < 0.0001) but also with pulmonary vascular resistance (PVR; r =–0.60; P < 0.0001). Conclusions: Shorter duration between RVOT and LVOT ejection is likely to explain the closely split second heart sound in cPH patients. When accurate echocardiographic assessment of RV function in cPH patients remains problematic due to the unusual geometry of this cardiac chamber; Doppler measures can simplify patient identification and follow up. (Echocardiography 2011;28:509‐515     

Echocardiographic and Doppler Findings in Primary Sarcoma of the Pulmonary Artery

Primary sarcoma of the pulmonary artery is a rare heart tumor. In the reported case, the clinical findings were nonspecific, and were characterized by progressive dyspnea, fever, and a systolic murmur in the pulmonary area. Echocardiographic examination showed an echogenic mass partially obstructing the pulmonary artery trunk, dilation of the right cardiac chambers, and a pressure overload pattern. Doppler and color Doppler demonstrated a high-velocity systolic flow jet in the pulmonary artery due to obstruction of the vessel by the tumor, as well as severe high-velocity tricuspid regurgitation. The patient died suddenly soon thereafter. The autopsy confirmed almost total occlusion of the pulmonary artery by a neoplastic mass. Histopathological diagnosis was primary vascular leiomyosarcoma of the pulmonary artery. In addition, a large tumor embolus had occluded the right pulmonary artery. Doppler echocardiography proved useful in noninvasively recognizing the sarcoma of the pulmonary artery, and explaining the clinical picture and hemodynamic derangements produced by this tumor. This could, in other patients, allow an early diagnosis and timely surgical intervention.     

Triage patients with suspected pulmonary embolism in the emergency department using a portable ultrasound device

The diagnosis of pulmonary embolism (PE) is difficult, despite validated diagnostic models. We sought to determine the value of a portable ultrasound device for triage of patients with suspected PE referred to the emergency department, using simplified echo criteria. We prospectively studied 103 consecutive patients with suspected PE, referred to our emergency department. After D-dimer screening, 76 patients were prospectively enrolled in this ultrasound study and underwent helical chest tomography, transthoracic echocardiography, and venous ultrasonography. Among patients with PE (n = 31), a right ventricular dilation was detected in 17 patients (55%), a direct visualization of clot in the lower limbs was present in 18 patients (58%), and 8 patients (26%) had both right ventricular dilation and deep venous thrombosis. The sensitivity and specificity of a combined ultrasound strategy using echocardiography and venous ultrasonography were respectively 87% (95% confidence interval 74% to 96%), and 69% (95% confidence interval 53% to 82%). The sensitivity of this combined strategy was significantly improved as compared to venous ultrasonography alone (P = 0.01) or echocardiography alone (P = 0.005). In patients with dyspnea or with high clinical probability of PE, this combined strategy was particularly relevant with high sensitivities (respectively 94% and 100%). Echocardiography combined with venous ultrasonography using a portable ultrasound device is a reliable method for screening patients with suspected PE referred to an emergency department, especially in patients with dyspnea or with high clinical probability.