A novel regional right ventricular wall-motion abnormality observed in a case of acute pulmonary embolism (reverse McConnell sign).

Among various echocardiographic parameters for diagnosis of pulmonary embolism, an abnormal regional contraction pattern of the right ventricular free wall consisting of normokinesia of the apical segment and akinesia of the midfree wall with persistence of abnormal wall motion at the base has proved to be fairly specific for pulmonary embolism. This echocardiographic abnormality has been termed "McConnell sign." We describe the case of a patient with acute pulmonary embolism who developed reversible akinesia of the apex and right ventricular midfree wall, a finding we would like to term "reverse McConnell sign."     

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

BackgroundRisk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition.ObjectivesIn this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality.MethodsThis was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality.ResultsThe pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37–31.86), RV enlargement (OR 4.02, 95% CI 1.43–11.34), and a McConnell sign (OR 2.79, 95% CI 1.09–7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74–53.32).ConclusionIn patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.     

The right ventricle and critical illness: a review of anatomy,physiology, and clinical evaluation of its function

This paper reviews right ventricular anatomy and physiology in the critically ill patient. The role of right ventricular function during acute pulmonary artery hypertension and the effect of acute myocardial injury upon right ventricular performance are examined. Clinical methods of assessing right ventricular function at the bedside in acutely ill patients are critically reviewed.     

The right ventricle and critical illness: a review of anatomy, physiology, and clinical evaluation of its function

This paper reviews right ventricular anatomy and physiology in the critically ill patient. The role of right ventricular function during acute pulmonary artery hypertension and the effect of acute myocardial injury upon right ventricular performance are examined. Clinical methods of assessing right ventricular function at the bedside in acutely ill patients are critically reviewed.     

Deciding when hemodynamic monitoring is appropriate. How will the data affect your diagnostic or therapeutic approach?

Hemodynamic data can be used to differentiate a variety of cardiopulmonary disorders, including right ventricular dysfunction, massive pulmonary embolism, and precapillary pulmonary hypertension. In patients with acute pulmonary edema, low-output states, or shock, hemodynamic measurements can help guide therapy; they also provide a precise estimate of a patient's response to vasoactive or inotropic drugs. Consider a flotation catheter for patients with complicated MIs, critically ill patients with multiorgan or major organ dysfunction, and high-risk cardiac patients undergoing surgery.     

经胸超声心动图诊断急性肺动脉栓塞的价值

目的　探讨经胸超声心动图 (transthoracic echocardiography,TTE)对急性肺动脉栓塞 (acute pulmonary embolism,APE)的诊断价值。方法　分析 16例确诊为 APE患者的 TTE表现 ,与肺动脉造影、肺核素扫描及计算机体层摄影对照。结果　超声直接检出主肺动脉及左、右肺动脉主干近段血栓者 6例 ,均被 CT或肺动脉造影证实 ,其中超声还直接检出右室内血栓 3例、右房内血栓 1例 ;本组资料具有右心负荷过重超声征象者 12例 (其中包括超声直接检出血栓的 6例 ) ,CT或核素肺灌注 /通气扫描提示为双肺多发性大面积栓塞 ;TTE检查大致正常者 4例 ,但核素肺灌注 /通气扫描或者 CT均提示为肺段或亚段栓塞。结论　经胸超声心动图可发现主肺动脉、左右肺动脉干内血栓直接提示肺动脉栓塞 ,或根据右心负荷过重表现并结合临床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。     

Concurrent pulmonary embolism and acute coronary syndrome with dynamic electrocardiographic changes

Concomitant occurrence of pulmonary embolism and acute coronary syndrome is rare. The early diagnosis and treatment of acute coronary syndrome with right ventricular myocardial ischemia during acute pulmonary embolism (APE) are crucial. The irreversible right ventricular myocardial dysfunction is a major risk factor for mortality from APE. In this case report, we present a 66-year-old female patient with APE who had a significant right coronary artery (RCA) lesion, which was successfully treated with angioplasty and stent implantation.     

Weaning failure due to acute neuromuscular disease

Two patients who required ventilatory support for acute pulmonary disease failed to be weaned when they developed the Guillain-Barré syndrome. Respiratory muscle weakness was a major sign of their acute neuromuscular disease because the manifestations of critical illness obscured the progressive paralysis. Both cases illustrate the difficulty in diagnosing acute neuromuscular syndromes in critically ill patients.     

Monitoring of right-sided heart function

PURPOSE OF REVIEW: Because the right side of the heart supplies blood to the pulmonary circulation, its integrity is required for both adequate respiratory and circulatory function. By reducing pulmonary perfusion, right-sided heart failure may compromise arterial oxygenation and left ventricular filling, and monitoring of right-sided heart function at the bedside in critically ill patients is fundamental. Two recent clinical commentaries have focused on the invaluable help provided by echocardiography for this purpose. RECENT FINDINGS: Bedside echocardiography has supplanted invasive procedures as the best tool to evaluate right-sided heart function. Although not recent, this technique, previously reserved for cardiologists, has recently gained a larger acceptance in respiratory intensive care units. Echocardiographic examination detects excessive right ventricular afterload, visualized by septal dyskinesia, and its usual consequence, right ventricular enlargement, which impairs left ventricular filling. SUMMARY: Monitoring of right-sided heart function is essential in a clinical setting associated with hemodynamic instability, such as severe sepsis or acute coronary artery obstruction, and also in that it is associated with increased pulmonary vascular resistance, as in massive pulmonary embolism or acute respiratory failure. Moreover, use of mechanical ventilation requires regular evaluation of its effects on the right side of the heart.     

McConnell's sign: Echocardiography in the management of acute pulmonary embolism

Management of acute pulmonary embolism depends immensely on rapid diagnosis and early intervention. Transthoracic echocardiography has gained favorability in scenarios where diagnostic computed tomography angiography is not feasible. McConnell''s sign, an echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing, is highly specific and may guide therapeutic intervention. We present the case of a 59‐year‐old man who was found to have acute pulmonary embolism with obstructive shock, managed successfully with thrombolytic therapy after identification of McConnell''s sign. We review current literature and develop a framework for the integration of echocardiography into the multimodal approach to management.     

核素肺显像对鉴别貌似炎症的急性肺栓塞及真正肺部炎症的价值

目的研究核素肺吸入、灌注显像对鉴别貌似炎症的急性肺栓塞及真正肺部炎症的价值。消除由于误诊耽误最佳溶栓时机的危险。方法对１４例伴有胸痛、咳嗽或发热的急性肺栓塞及１０例肺部炎症患者进行核素肺吸入灌注显像。以其损伤肺段当量数占被检肺段的百分比及其形态学改变对两种疾病在两种显像中的表现进行比较分析。并与Ｘ线胸片进行对比。结果急性肺动脉栓塞肺灌注显像示以肺段分布的异常放射性缺损区,损伤肺段当量数占被检肺段的２７％;吸入显像基本正常,仅占０４％。反之,肺部炎症则示吸入损伤明显,按或不按肺段分布,占被检肺段的４０％;灌注显像占２４％,部位与吸入像匹配,多为放射性减低。急性肺栓塞的Ｘ线胸片为正常、血管纹理减少或非特异改变;而肺部炎症则改变明显。结论急性肺动脉栓塞尤其貌似炎症者核素显像诊断价值较高。肺部炎症动态观察Ｘ线胸片诊断价值较高。但核素显像亦有能区别于栓塞的特点。肺栓塞合并炎症者,核素显像、特别是动态观察具有独特价值。灌注显像损伤范围可大于吸入影像损伤范围,病变呈以肺段形态分布的放射性缺损。而单纯炎症吸入影像损伤范围大于灌注,且灌注像可为不按肺段分布的放射性减低     

Diagnosis of pulmonary embolism by acute right heart morphologic and hemodynamic changes observed during exercise stress echocardiography.

In addition to the conventional means of diagnosing pulmonary embolism, resting echocardiography has sometimes been useful. We describe the case of a patient with a normal resting transthoracic echocardiogram, but with a markedly abnormal posttreadmill exercise echocardiogram revealing acute right ventricular dilatation, marked ventricular septal shift, and acute pulmonary hypertension. Pulmonary embolism was suspected and subsequently confirmed by chest computed tomographic angiography.     

Evaluation of right ventricular dysfunction and prediction of clinical outcomes in acute pulmonary embolism by chest computed tomography: comparisons with echocardiography

To evaluate the ability to identify right ventricular (RV) dysfunction, and to predict adverse outcomes of chest computed tomography (CT), we compared CT and echocardiography in acute pulmonary embolism patients. We analyzed 56 patients diagnosed by CT with acute pulmonary embolism, who underwent echocardiography within 48 h of CT scan from January 2004 to December 2008. From the CT scan, the ratio of RV diameter to left ventricular diameter (RVd/LVd), the presence of septal bowing and embolus location were determined. RVd/LVd (P < 0.001), septal bowing (P < 0.001) and proximal embolism (P = 0.016) were associated with echocardiographic RV hypokinesia. The odds ratio for adverse clinical outcomes was 19.2 for the combination of three CT parameters (RVd/LVd > 1, septal bowing, and proximal embolism), and 13.4 for RV hypokinesia (each P = 0.001). The positive predictive value (PPV) for adverse clinical outcomes for echocardiographic RV hypokinesia was 55.0%, and the negative predictive value (NPV) was 96.2%. The three-parameter combination predicted adverse clinical outcomes with a PPV of 54.5%, and a NPV of 94.1%. CT parameters including RV dysfunction were significantly associated with poor outcomes. Rapid risk stratification of patients with acute pulmonary embolism based on chest CT appears to be comparable with echocardiography, is clinically reliable, and may be useful in guiding management strategy.     

What role does the right side of the heart play in circulation?

Right ventricular failure (RVF) is an underestimated problem in intensive care. This review explores the physiology and pathophysiology of right ventricular function and the pulmonary circulation. When RVF is secondary to an acute increase in afterload, the picture is one of acute cor pulmonale, as occurs in the context of acute respiratory distress syndrome, pulmonary embolism and sepsis. RVF can also be caused by right myocardial dysfunction. Pulmonary arterial catheterization and echocardiography are discussed in terms of their roles in diagnosis and treatment. Treatments include options to reduce right ventricular afterload, specific pulmonary vasodilators and inotropes.     

Management strategies for patients with pulmonary hypertension in the intensive care unit

OBJECTIVE: Pulmonary hypertension may be encountered in the intensive care unit in patients with critical illnesses such as acute respiratory distress syndrome, left ventricular dysfunction, and pulmonary embolism, as well as after cardiothoracic surgery. Pulmonary hypertension also may be encountered in patients with preexisting pulmonary vascular, lung, liver, or cardiac diseases. The intensive care unit management of patients can prove extremely challenging, particularly when they become hemodynamically unstable. The objective of this review is to discuss the pathogenesis and physiology of pulmonary hypertension and the utility of various diagnostic tools, and to provide recommendations regarding the use of vasopressors and pulmonary vasodilators in intensive care. DATA SOURCES AND EXTRACTION: We undertook a comprehensive review of the literature regarding the management of pulmonary hypertension in the setting of critical illness. We performed a MEDLINE search of articles published from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary hypertension, vasopressor agents, therapeutics, critical illness, intensive care, right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both human and animal studies related to pulmonary hypertension were reviewed. CONCLUSIONS: Pulmonary hypertension presents a particular challenge in critically ill patients, because typical therapies such as volume resuscitation and mechanical ventilation may worsen hemodynamics in patients with pulmonary hypertension and right ventricular failure. Patients with decompensated pulmonary hypertension, including those with pulmonary hypertension associated with cardiothoracic surgery, require therapy for right ventricular failure. Very few human studies have addressed the use of vasopressors and pulmonary vasodilators in these patients, but the use of dobutamine, milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest support in the literature. Treatment of pulmonary hypertension resulting from critical illness or chronic lung diseases should address the primary cause of hemodynamic deterioration, and pulmonary vasodilators usually are not necessary.     

Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography

Immediate coronary catheterization is mandatory for high risk patients with typical chest pain in the emergency department (ED). In contrast, in ED patients with acute chest pain but low to intermediate risk, traditional management protocol includes serial ECG, cardiac troponins and radionuclide perfusion imaging. However, this protocol is time-consuming and expensive, and definite treatment of unstable angina is often delayed. Due to advances of multi-detector CT (MDCT) technology, dedicated coronary CT angiography provides the potential to rapidly and reliably diagnose or exclude acute coronary syndrome in ED patients with acute chest pain. Moreover, major life-threatening causes of ED chest pain (i.e., acute aortic syndrome and pulmonary embolism as well as acute coronary syndrome) can simultaneously be assessed by the so-called “triple rule-out” protocol with a single scan. In ED patients with atypical chest pain and low to intermediate risk, the triple rule-out protocol may be preferred, especially in older patients who have relatively lower risk of lifelong radiation-induced cancer. However, the increased radiation dose resulting from the extended volume coverage with this protocol should be fully considered prior to performing this protocol. Therefore, in ED patients who have a low clinical suspicion of pulmonary embolism and acute aortic syndrome, especially younger patients, dedicated coronary CT angiography accompanied by modifications to reduce radiation dose is recommended.     

肺栓塞的超声诊断价值探讨

目的探讨肺栓塞的超声诊断价值。方法将CT肺动脉血管造影(CTPA)诊断为肺栓塞的15例患者,行心脏、胸腔、四肢静脉的彩色多普勒超声检查。结果所有病例超声未发现肺栓塞的直接征象;但可发现一些间接征象如:6例发现右心增大,少~大量三尖瓣反流,肺动脉压升高;7例发现肺动脉血流流速曲线上的RPEP/RVET比值升高>0.30;2例发现肺部梗塞区;6例发现下肢静脉血栓形成;5例发现下肢静脉血流淤滞。结论超声发现肺栓塞直接征象的几率较低,不能作为确诊肺栓塞的主要检查方法。但超声能发现一些肺栓塞的间接征象,对临床的诊断、治疗和观察疗效有重要意义。     

Acute rheumatic fever mimicking an acute coronary syndrome

An elevated troponin measurement does not always reflect myocardial ischaemia secondary to obstructive coronary artery disease. Troponin levels can also be elevated in other disease states including pulmonary emboli, myo‐pericarditis, acute rheumatic fever, and in the critically ill. Thus, patients presenting with chest pain and electrocardiological and biochemical evidence of myocardial necrosis are not always suffering from an acute coronary syndrome.     

Thoracic epidural anesthesia impairs the hemodynamic response to acute pulmonary hypertension by deteriorating right ventricular-pulmonary arterial coupling

OBJECTIVE: Thoracic epidural anesthesia is increasingly used in critically ill patients. This analgesic technique was shown to decrease left ventricular contractility, but effects on right ventricular function have not been reported. A deterioration of right ventricular performance may be clinically relevant for patients with acute pulmonary hypertension, in which right ventricular function is an important determinant of outcome. In the present study, we tested the hypothesis that thoracic epidural anesthesia decreases right ventricular contractility and limits its capacity to tolerate pulmonary hypertension. DESIGN: Prospective, placebo-controlled study using an established model of acute pulmonary hypertension. SETTING: University hospital laboratory. SUBJECTS: A total of 14 pigs (mean weight, 35 +/- 2 kg). INTERVENTIONS: After instrumentation with an epidural catheter, biventricular conductance catheters, a pulmonary flow probe, and a high-fidelity pulmonary pressure catheter, seven pigs received thoracic epidural anesthesia and seven pigs served as control. Hemodynamic measurements were performed in baseline conditions and after induction of pulmonary hypertension via hypoxic pulmonary vasoconstriction (Fio2 of 0.15). MEASUREMENTS AND MAIN RESULTS: Ventricular contractility was assessed using load- and heart rate-independent variables. Right ventricular afterload was characterized with instantaneous pressure-flow measurements. In baseline conditions, thoracic epidural anesthesia decreased left but not right ventricular contractility. In untreated animals, pulmonary hypertension was associated with an increase in right ventricular contractility and cardiac output. Pretreatment with thoracic epidural anesthesia completely abolished the positive inotropic response to acute pulmonary hypertension. As a result, ventriculo-vascular coupling between the right ventricle and pulmonary-arterial system deteriorated, and cardiac output was significantly lower in animals with thoracic epidural anesthesia than in untreated controls during hypoxia-induced pulmonary hypertension. CONCLUSIONS: Thoracic epidural anesthesia inhibits the native positive inotropic response of the right ventricle to increased afterload and deteriorates the hemodynamic effects of acute pulmonary hypertension.     

Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVES: To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN: Case report. SETTING: Intensive care unit of a university hospital. PATIENT: A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION: Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS: Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.