Multiplane Transesophageal Echocardiographic Detection and Differential Diagnosis of Isolated Right Pulmonary Artery Agenesis

We present a case report of isolated right pulmonary artery agenesis detected by multiplane trans-esophageal echocardiography (TEE). A special emphasis is placed on its important role in the differential diagnosis and hemodynamic and functional evaluation of patients with unilateral pulmonary oligemia on chest radiograph. We also present a case report of pulmonary embolism with complete obstruction of the right pulmonary artery for better understanding and for comparison of TEE images in patients with pulmonary artery agenesis.     

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.     

Color Doppler Transesophageal Echocardiography in Detection of Massive Pulmonary Embolism

In this article, the potential value of color Doppler in improving diagnostic accuracy of transesophageal echocardiography (TEE) in patients with incomplete obstruction of large pulmonary vessels is illustrated, We present an unusual case of massive pulmonary embolism that was unequivocally detected by color Doppler TEE both before and after pulmonary angiography, which failed to demonstrate filling defects in the pulmonary artery.     

Right pulmonary artery occlusion secondary to a dissecting aortic aneurysm

This report describes a case of right pulmonary artery obstruction caused by a dissecting aneurysm of the thoracic aorta. Initial ventilation-perfusion (V/Q) scan revealed no perfusion to the right lung. Lack of right lung perfusion plus other clinical abnormalities led to an initial diagnosis of massive embolism in the right lung. Bilateral pulmonary arteriography of the thoracic and abdominal aorta revealed extrinsic compression of the right pulmonary artery near its origin and the suggestion of an ascending aortic dissection. Subsequent ascending aortography and computed tomography (CT) confirmed a dissection of the ascending aorta. Aortography in the true lumen of the aorta revealed trivial aortic insufficiency. These diagnostic procedures confirmed the presence of an acute dissecting aneurysm of the ascending aorta that caused compression of the right pulmonary artery. The finding of a massive unilateral segmental defect with normal ventilation upon lung scanning does not always ensure a diagnosis of acute pulmonary embolus. Patient presentation with massive unilateral perfusion defect merits further evaluation with pulmonary arteriography.     

Importance of multiplane transesophageal echocardiography in the diagnosis of pulmonary embolism]

Pulmonary thromboembolism (PTE) is a clinical entity difficult to diagnose, its setting is often confused with other pathological entities. The inexistence of isotopic techniques in most centres and the difficulty and delay in performing a pulmonary angiography leads transesophageal echocardiography (TEE) to be, a method of increasing importance for its diagnosis. From January 1996 to November 1997, echocardiographic evaluation was requested for 33 patients due to clinical suspicion of pulmonary thromboembolism. A transthoracic assessment was made previously in 21 patients (average ages 58.3 years, 52% males) which had signs of right overload (dilatation of the right cavities, anomalous movement of the intraventricular septum and pulmonary hypertension) a TEE was performed. The TEE was negative in 10 patients (TEEn) without evidence of thrombi in the trunk and main branches of the pulmonary artery (PA); there was one death on this group for repeated pulmonary microembolisms confirmed by necropsy. The TEE was positive in 11 patients (TEEp) with evidence of thrombi in the PA trunk in 3 patients, bilaterally in both branches in 3 patients and in the right branch in 5 patients. There were dilatations of the right cavities in all patients, paradoxal movement of the interventricular septum and bulging of the intra-auricular septum to the left atria. Foramen ovale was detected in 2 patients. The best visualisation of the PA was achieved in the intermediate planes between 30-70 degrees and between 90-130 degrees (plane for transverse slice of the right branch of the pulmonary artery). In 7 patients with TEEp, PTE was confirmed by CT-scan (visualisation of the thrombi in the trunk and main branches of the PA) and/or ventilation-perfusion scintigraphy and/or pulmonary angiography. In three cases of massive pulmonary embolism in young patients, with severe pulmonary hypertension, thrombolysis was performed with rTPA, under TEE control before and after rTPA in one of the cases. In conclusion, transesophageal echocardiography is an easy technique to be performed in the case of clinical suspicion of PTE. The existence of a negative examination does not invalidate the existence of PTE since only the trunk and the main branches of the PA are accessible by this technique. The detection of thrombi at this level in patients with clinical suspicion of massive pulmonary embolism confirms the diagnosis and supports the indication of thrombolysis.     

Massive pulmonary embolism immediately diagnosed by transthoracic echocardiography and treated with tenecteplase fibrinolysis

We report the case of a 75-year-old woman with new onset dyspnoea, hypotension, and right bundle branch block. Transthoracic echocardiography (TTE) showed a thrombus in the right pulmonary artery and acute pulmonary embolism was diagnosed. The patient immediately underwent fibrinolysis with tenecteplase, with prompt recovery of clinical conditions and ECG anomalies. Bedside TTE might be helpful for immediate diagnosis of massive PE needing rapid treatment by fibrinolysis.     

以胸腔积液为首诊的肺栓塞19例临床分析

目的分析以胸腔积液为首诊的肺栓塞患者的临床特点,增强对症状不典型肺栓塞的认识,降低误诊率。方法回顾性分析19例以胸腔积液为首要临床表现的肺栓塞患者的临床特点。结果 71例肺栓塞患者中19例出现胸腔积液,占26.76%;大量胸腔积液1例,中量2例,少量16例;双侧胸腔积液2例,单侧胸腔积液17例,其中右侧8例,左侧9例;3例行胸腔穿刺胸水常规化验均为渗出性胸水。结论胸腔积液是肺栓塞的非典型、非特异性临床表现,临床上要提高警惕,及时完善D-二聚体检测,CT肺动脉造影检查,以提高确诊率。     

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。     

Obstruction of the right pulmonary artery by an aortic aneurysm complicating previous coronary bypass grafting

We report a case of right main pulmonary artery compression due to a type II dissecting aortic aneurysm simulating massive pulmonary artery embolism. Aortic tear and intimal splitting developed around an aortocoronary bypass graft performed 11 months earlier. Ultrasound detected the aortic aneurysm and pulmonary hypertension, and excluded emboli in the pulmonary artery. Pulmonary angiography explained the lung involvement, showing compression of the right main pulmonary artery. Coronary and aortic angiograms demonstrated that the aortic aneurysm developed around the right venous bypass graft. Surgery confirmed the anglographic findings and the pathogenesis of the syndrome. © Wiley-Liss, Inc.     

Color Doppler Transesophageal Echocardiography in Detection of Massive Pulmonary Embolism: Is Pulmonary Angiography Always the Gold Standard?

In this article, the potential value of color Doppler in improving diagnostic accuracy of transesophageal echocardiography (TEE) in patients with incomplete obstruction of large pulmonary vessels is illustrated. We present an unusual case of massive pulmonary embolism that was unequivocally detected by color Doppler TEE both before and after pulmonary angiography, which failed to demonstrate filling defects in the pulmonary artery. (ECHOCARDIOGRAPHY, Volume 13, November 1996)     

合并复杂病情的急性大面积肺栓塞的溶栓治疗

目的 :评价急性大面积肺栓塞合并复杂病情的溶栓疗效。方法 :对急性大面积肺栓塞合并复杂病情的 7例患者于溶栓前、后行心电图、动脉血气、超声心动图、肺灌注显像及电子束计算机断层摄影术 (EBCT)检查 ,评价溶栓疗效。结果 :7例大面积肺栓塞患者合并复杂病情 ,包括 :例 1合并妊娠、例 2和例 3反复发生肺栓塞、例 4并发休克、例 5并发矛盾性右肾动脉及肠系膜动脉栓塞、例 6为 82岁高龄及例 7肺灌注显像正常 ,而EBCT显示大块血栓堵塞主肺动脉内。 6例予重组组织型纤溶酶原激活剂 ,1例予尿激酶溶栓治疗。溶栓前平均动脉血氧分压及动脉二氧化碳分压分别为 62 9mmHg(1mmHg =0 133kPa)、31 6mmHg ,溶栓后分别上升至 82 0mmHg、36 6mmHg。超声心动图显示溶栓前右心室内径及估测肺动脉收缩压分别为 32 7mm、5 6 3mmHg ,溶栓后为 2 2 8mm、37 9mmHg。 7例肺灌注显像示溶栓前缺损肺段 7～ 15个不等 ,溶栓后 5例仅残余 3～ 5个肺段的缺损 ,肺灌注明显改善 ,2例正常。所有患者临床症状明显改善或完全消失 ,7例患者均好转出院。结论 :急性大面积肺栓塞合并复杂病情 ,如能得到正确诊断和及时有效的治疗 ,可挽救患者生命 ,改善预后。     

Diagnostic transcatheter aspiration for pulmonary artery tumor embolism using an INARI Triever aspiration catheter

Pulmonary artery tumor embolism is a rare phenomenon and its diagnosis is important because of a poor prognosis. We report a 20-year-old male with history of metastatic osteosarcoma who presented with acute pulmonary embolism. He was urgently taken to the catheterization laboratory and underwent transcatheter aspiration of pulmonary artery mass using an INARI Triever aspiration catheter. Pathology of the aspirated specimen lead to the diagnosis of pulmonary artery tumor embolism, not thrombus. This case highlights the diagnostic utility of transcatheter aspiration for the pulmonary artery tumor embolism.     

Occluding the pulmonary artery to improve detection of patent foramen ovale during ventricular assist device placement

Unrecognized patent foramen ovale (PFO) in patients after left ventricular assist device (VAD) placement could cause significant hypoxemia and paradoxical embolism. We aim to improve the techniques for PFO detection in this patient population before left ventricular device initiation. We evaluated the effects of main pulmonary artery occlusion on patients' hemodynamic and detection of PFO by transesophageal echocardiography (TEE). We compared between the standard and pulmonary artery occlusion technique. Sixty-two patients with ASA physical status class IV were studied. They presented with end-stage heart failure for left VAD placement. All patients received both Valsava maneuver and occlusion of their pulmonary arteries to assess their influence on detection of PFO. Occlusion of the main pulmonary artery consistently increased right atrial to left atrial pressure gradient. The PFO detection rate using TEE was significantly improved from 0% to 10% by this maneuver compared with the Valsava maneuver. Occlusion of the main pulmonary artery is a simple and effective method to improve PFO detection by TEE before left VAD initiation.     

Visualization of the central pulmonary arteries by biplane transesophageal echocardiography

It is suggested that transesophageal echocardiography (TEE), by detecting thromboemboli in the proximal parts of the pulmonary arteries, is useful in the diagnosis of pulmonary embolism. However, the data on visualization of the pulmonary arteries are limited. The extent of the pulmonary arteries that can be precisely visualized during biplane TEE was assessed in 51 consecutive patients (23 female, 28 male, aged 56.6±12.5 years) without structural heart disease. The main pulmonary artery and the right pulmonary artery were detected in 96.1% and 94.1% of patients, respectively. Although the proximal part of the left pulmonary artery was found in only 47.0% of patients, its distal part was visualized in 92.2%. During TEE, proximal parts of the lobar arteries on both sides were visualized in 88.2% of patients. Thus, the central pulmonary arteries including proximal parts of the lobar branches can be precisely visualized by biplane TEE in the majority of patients. Only the proximal part of the left pulmonary artery is difficult to assess.     

Pulmonary artery sarcoma mimicking massive pulmonary embolus: a case report

Intimal sarcomas of the pulmonary artery are rare tumors that are often difficult to distinguish from pulmonary thromboembolic disease, complicating accurate diagnosis and timely therapy. We report the case of a gentleman with a primary pulmonary artery sarcoma who presented with a massive pulmonary embolism and complete right ventricular outflow tract obstruction. The patient's condition was successfully managed with urgent pulmonary artery thromboendarterectomy, pulmonary valve replacement, and tricuspid valve annuloplasty.     

Experiences in the diagnosis and therapy of so-called thrombus in transit

With the increasing use of cross-sectional echocardiography in patients with overt or suspected pulmonary thromboembolism in the emergency rooms, more and more right atrial thrombi are detected. These are so-called "transitthrombi" from the venous system on their way to the pulmonary arteries and they are a severe presentation of thromboembolic disease. They appear as an imminent pulmonary embolism and usually coexists with an already massive embolism. In patients were a right atrial thrombus is associated with a patent foramen ovale, paradoxical arterial embolism has been observed. Right sided heart thrombi have a high mortality rate and need immediate treatment. In our hospital we have seen 14 patients with right atrial thrombi and pulmonary embolism in a period of 6 years. Three patients had cardiac arrest with a massive pulmonary embolism, seven patients presented with a submassive embolism. All patients were treated immediately after echocardiographic diagnosis without pulmonary angiography. In about half of the cases transesophageal echocardiography was done additionally for diagnosis and monitoring. Therapeutic options were thrombectomy, fibrinolysis or anticoagulants. We treated one of our patients with thrombectomy, eleven patients with fibrinolysis and two patients with anticoagulants.     

Streptokinase and heparin versus heparin alone in massive pulmonary embolism: A randomized controlled trial

To test the efficacy of thrombolytic therapy in massive pulmonary embolism, we conducted a prospective randomized controlled trial. Eight patients were randomized to receive either 1,500,000 IU of streptokinase in 1 hour through a peripheral vein followed by heparin or heparin alone. All patients had major risk factors for deep vein thrombosis (DVT) and were considered to have high clinical suspicion for pulmonary embolism (PE). At baseline all patients had a similar degree of systemic arterial hypotension, pulmonary arterial hypertension, and right ventricular dysfunction. The time of onset of cardiogenic shock in both groups was comparable (2.25 ±0.5 hours in the streptokinase group and 1.75 ±0.96 hours in the heparin group). The four patients who were randomized to streptokinase improved in the first hour after treatment, survived, and in 2 years of follow-up are without pulmonary arterial hypertension. All four patients treated with heparin alone died from 1 to 3 hours after arrival at the emergency room (p=0.02). Post-thrombolytic therapy the diagnosis of PE was sustained in the streptokinase group by high probability V/Q lung scans and proven DVT. A necropsy study performed in three patients in the heparin group showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. The results indicate that thrombolytic therapy reduces the mortality rate of massive acute pulmonary embolism.     

Pulmonary Artery Sarcoma Mimicking Pulmonary Embolism

Primary sarcomas that arise from major blood vessels are exceedingly rare, and some of the published cases have been autopsy reports. Most patients are adults. We report a case of pulmonary artery sarcoma in a 77-year-old man who presented with acute onset of dyspnea. Magnetic resonance imaging of the chest revealed a large mass within the pulmonary trunk and its main branches. Because massive pulmonary embolism was suspected, both anticoagulant and thrombolytic therapies were initiated. The patient responded poorly to these therapies, which then necessitated resection of both the mass and the pulmonary valve. A bioprosthetic porcine valve replaced the native valve, and we reconstructed the right ventricular outflow tract with a Dacron patch. Histopathologic examination revealed a high-grade sarcoma with focal myogenic and chondrogenic differentiation. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 7. He was subsequently treated with chemotherapy and radiation and continued to show no evidence of disease.The diagnosis of pulmonary artery sarcoma should be suspected in patients who present with manifestations of pulmonary embolism, especially when there is no evidence of deep venous thrombosis and poor response to anticoagulant therapy. Multimodal therapy can provide prolonged survival.     

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.     

Impending paradoxical embolism: A case report and literature review

Paradoxical embolism occurs following the passage of embolicmaterial from the venous to the arterial circulation througha right to left shunt—frequently a patent foramen ovale.The diagnosis is usually presumptive when arterial emboli occurin the appropriate clinical setting. We describe a case of impendingparadoxical embolism in a patient with massive pulmonary embolism.Transoesophageal echocardiography revealed a thromboembolusstraddling a patent foramen ovale. The patient underwent emergencyremoval of the intracardiac clot with closure of the patentforamen ovale.