Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction

The aim of this study was to prospectively evaluate the accuracy of quantitative cardiac computed tomography (CT) parameters and two cardiac biomarkers (N-terminal-pro-brain natriuretic peptide (NT-pro-BNP) and troponin I), alone and in combination, for predicting right ventricular dysfunction (RVD) in patients with acute pulmonary embolism. 557 consecutive patients with suspected pulmonary embolism underwent pulmonary CT angiography. Patients with pulmonary embolism also underwent echocardiography and NT-pro-BNP/troponin I serum level measurements. Three different CT measurements were obtained (right ventricular (RV)/left ventricular (LV)(axial), RV/LV(4-CH) and RV/LV(volume)). CT measurements and NT-pro-BNP/troponin I serum levels were correlated with RVD at echocardiography. 77 patients with RVD showed significantly higher RV/LV ratios and NT-pro-BNP/troponin I levels compared to those without RVD (RV/LV(axial) 1.68 ± 0.84 versus 1.00 ± 0.21; RV/LV(4-CH) 1.52 ± 0.45 versus 1.01 ± 0.21; RV/LV(volume) 1.97 ± 0.53 versus 1.07 ± 0.52; serum NT-pro-BNP 6,372 ± 2,319 versus 1,032 ± 1,559 ng · L(-1); troponin I 0.18 ± 0.41 versus 0.06 ± 0.18 g · L(-1)). The area under the curve for the detection of RVD of RV/LV(axial), RV/LV(4-CH), RV/LV(volume), NT-pro-BNP and troponin I were 0.84, 0.87, 0.93, 0.83 and 0.70 respectively. The combination of biomarkers and RV/LV(volume) increased the AUC to 0.95 (RV/LV(volume) with NT-pro-BNP) and 0.93 (RV/LV(volume) with troponin I). RV/LV(volume) is the most accurate CT parameter for identifying patients with RVD. A combination of RV/LV(volume) with NT-pro-BNP or troponin I measurements improves the diagnostic accuracy of either test alone.     

Pulmonary embolism with isolated right ventricular infarction.

Concomitant occurrence of pulmonary embolism and right ventricular infarction is rare. It poses important diagnostic and therapeutic implications. A case of pulmonary embolism with isolated right ventricular anterior wall infarction presented with ventricular tachycardia. One pathology could have led to the other. Two-dimensional echocardiography was useful in documenting pulmonary artery hypertension as well as regional wall motion abnormality of the right ventricle. Thrombolytic therapy and dobutamine infusion were useful. Nitrates, fluid infusion and diuretics should be used cautiously.     

Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction.

BACKGROUND: A normally contracting right ventricular apex associated to a severe hypokinesia of the mid-free wall ('McConnell sign') has been considered a distinct echocardiographic pattern of acute pulmonary embolism. OBJECTIVE: To evaluate the clinical utility of the 'McConnell sign' in the bedside diagnostic work-up of patients presenting to the Emergency Department with an acute right ventricular dysfunction due to pulmonary embolism or right ventricular infarction. DESIGN: Among 201 patients, consecutively selected from our clinical database and diagnosed as having massive or submassive pulmonary embolism or right ventricular infarction, 161 were suitable for an echocardiographic review of regional right ventricular contraction and were included in the study. There were 107 cases with pulmonary embolism (group 1) and 54 cases with right ventricular infarction (group 2). All echocardiographic studies were randomly examined by two experienced and independent echocardiographers, blinded to the patient diagnosis and without Doppler informations. RESULTS: The McConnell sign was detected in 75 of 107 patients in group 1 (70%) and in 36 of 54 patients in group 2 (67%); the finding was absent in 32 cases in group 1 and in 18 cases in group 2 (P=0.657). The sensitivity, specificity, positive and negative predictive values of the McConnell sign for the diagnosis of pulmonary embolism were respectively 70, 33, 67 and 36%. CONCLUSIONS: In a clinical setting of patients with acute right ventricular dysfunction the McConnell sign cannot be considered a specific marker of pulmonary embolism.     

右室功能异常对血压正常肺栓塞预后影响

目的研究右心室功能异常对血压正常肺栓塞患者临床和预后的影响。方法2001年1月至2004年12月入住本院就诊时血压正常确诊肺栓塞患者,超声心动图检查右室扩张、肺动脉高压作为右室功能异常定量诊断标准。分为血压正常肺栓塞右室功能异常组和正常组,对临床情况进行回顾性分析。结果57例血压正常肺栓塞患者其中27例右室功能异常,30例右室功能正常。右室功能异常组与正常组肺栓塞相关病死率为19％比0％,差异有统计学意义。结论右室功能异常是增加肺栓塞病死率的一个重要因素。超声心动图能较好地评价右室功能状况,可识别出具有高度死亡危险性的人群。     

The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism

The prognosis and optimal therapy of patients with pulmonary embolism (PE) are strongly influenced by the presence or absence of associated hemodynamic derangements. Patients with normal systemic arterial pressure have a relatively low risk of recurrent PE and death when treated promptly with therapeutic anticoagulation. Those who present with hypotension, shock, or cardiac arrest, however, have a much higher mortality rate and often receive thrombolytic therapy. Recent evidence indicates that the presence of right ventricular (RV) dysfunction identifies a subgroup of normotensive patients with a much more guarded prognosis who may benefit from more intensive therapy with thrombolytic agents. This article reviews our current understanding of the pathophysiology and diagnosis of RV dysfunction and its impact on the prognosis and therapy of normotensive patients with PE.     

Prognostic role of biomarkers and right ventricular dysfunction in pulmonary embolism

Pulmonary embolism is morbidity and mortality remain high. The short-term prognosis of pulmonary embolism depends on haemodynamic status and underlying disease massive pulmonary embolism, defined as pulmonary embolism that is associated with systemic hypotension which increases up to 50% in hospital mortality. However, the in-hospital mortality of patients with normal blood pressure pulmonary embolism has been reported to vary from 3 to 15%. Right ventricular dysfunction showed by echocardiography or computerized tomography and elevated cardiac enzymes have been used to determine mortality in these patients with pulmonary embolism. In this article; we reviewed the prognostic value of right ventricular dysfunction as evaluated by echocardiography or spiral computerized tomography, and the prognostic value of increased levels of cardiac markers in patients with pulmonary embolism.     

Role of electrocardiography in identifying right ventricular dysfunction in acute pulmonary embolism

The role of electrocardiography in identifying right ventricular (RV) dysfunction in acute pulmonary embolism (APE) was evaluated in 81 patients with APE. The electrocardiographic markers studied were T-wave inversion in leads V1 to V3, the S1Q3T3 pattern, right bundle branch block, and sinus tachycardia. T-wave inversion in leads V1 to V3 had the greatest sensitivity and diagnostic accuracy for identifying RV dysfunction in patients with APE. The S1Q3T3 pattern and right bundle branch block had good specificity but moderate accuracy.     

Utility of thallium-201 scintigraphy in detecting right ventricular dysfunction in pulmonary embolism

Acute right ventricular dysfunction has been established both as a diagnostic and prognostic indicator in pulmonary embolism. This report illustrates the utility of thallium-201 scintigraphy as an adjunctive noninvasive test in the diagnosis of pulmonary embolism by demonstrating increases in regional right ventricular perfusion and its subsequent resolution with treatment presumably as a result of decreased pressure work.     

Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism

BACKGROUND: Echocardiographically assessed right ventricular dysfunction is increasingly used to guide more aggressive therapy in hemodynamically stable patients with acute pulmonary embolism (PE). However, the prognostic value of right ventricular dysfunction in these patients is still unclear. METHODS: We systemically reviewed the literature to assess the prevalence of echocardiographic right ventricular dysfunction and the association with adverse outcomes in patients with PE who had this condition. The methodologic quality of each study was scored. Absolute risks of the outcome events were calculated for each study separately, and positive predictive values of PE-related mortality were determined for normotensive patients. RESULTS: Seven studies were included. All had methodologic shortcomings, but they suggested an at least 2-fold increased risk of PE-related mortality in patients with right ventricular dysfunction, the prevalence of which varied from 40% to 70%. However, this seems to be less convincing in hemodynamically stable patients. The only 2 studies that allowed for an estimation of the accuracy in normotensive patients showed low positive predictive values of echocardiographic right ventricular dysfunction for PE-related in-hospital mortality (positive predictive value, 4% and 5% in the 2 studies). CONCLUSION: It remains unclear whether echocardiographic right ventricular dysfunction is a prevalent and reliable predictor of adverse outcomes in hemodynamically stable patients with acute PE.     

Diagnosis of right ventricular dysfunction in acute pulmonary embolism using helical computed tomography

Forty-six consecutive patients with pulmonary embolism (PE) who underwent pulmonary angiography, helical computed tomography (CT), and echocardiography in the investigators' emergency department were studied. It was determined that the CT right ventricular (RV)/left ventricular (LV) end-diastolic area ratio was correlated with PE obstruction and echocardiography. A CT RV/LV area ratio >1 had a sensitivity of 88% and a specificity of 88% in diagnosing significant PE. The present study suggests that helical CT may be used as a triage tool in acute PE for selecting high-risk patients, using calculation of the RV/LV area ratio to detect RV dysfunction.     

急性肺栓塞并右心室功能不全心电图表现及临床应用

目的探讨急性肺栓塞(Acute Pulmonary Embolism APE)合并右心功能不全(Right Ventricular Dysfunction RVD)时心电图(ECG)的表现及临床应用价值。方法根据超声心动图(TTE)是否存在RVD,将105名APE患者分为:A组合并RVD 47例;B组无RVD 58例。分析比较两组患者的心电图表现及临床预后。结果 (1)心电图表现比较:T波倒置,V1-V3导联、V1及a VR导联ST段抬高,完全性右束支阻滞(complete right branch block CRBBB),SIQIIITIII,A组高于B组;(2)超声心动图指标:三尖瓣返流速度,肺动脉收缩压A组更高;(3)D-二聚体,达到临床终点的人数、中心肺动脉栓塞发生率A组更高。结论 APE合并RVD的患者临床预后差,更容易出现T波倒置,CRBBB,右胸及a VR导联ST段抬高,SIQIIITIII等一系列心电图表现。     

Pulmonary embolism due to right ventricular thrombus in a case of Behcet's disease

Right ventricular thrombus is a very rare manifestation of cardiovascular Behcet's disease. A 25-year-old man was admitted to hospital due to cough and fever of unknown origin. He experienced repetitive pulmonary embolism due to a right ventricular thrombus, which was surgically removed. A diagnosis of Behcet's disease was made based on his clinical course and the histological findings of the right ventricular wall and the skin lesion. He was quickly relieved of his symptoms after warfarinization and cyclosporine therapy.     

Cardiac inflammation contributes to right ventricular dysfunction following experimental pulmonary embolism in rats

Acute right ventricular (RV) failure following pulmonary embolism (PE) is a strong predictor of poor clinical outcome. Present studies test for an association between RV failure from experimental PE, inflammation, and upregulated chemokine expression. Additional experiments test if neutrophil influx contributes to RV dysfunction. PE was induced in male rats by infusing 24 microm microspheres (right jugular vein) producing mild hypertension (1.3 million beads/100 g, PE1.3), or moderately severe hypertension (2.0 million beads/100 g, PE2.0). Additional rats served as vehicle sham (0.01% Tween 20, Veh). In vivo RV peak systolic pressures (RVPSP) increased significantly, and then declined following PE2.0 (51 +/- 1 mm Hg 2 h; 49 +/- 1, 6 h; 44 +/- 1, 18 h). RV generated pressure of isolated, perfused hearts was significantly reduced in PE2.0 compared with PE1.3 or Veh. MCP-1 protein (ELISA) was elevated 21-fold and myeloperoxidase activity 95-fold in RV of PE2.0 compared with Veh or PE1.3. CINC-1, CINC-2, MIP-2, MCP-1, and MIP-1alpha mRNA also increased in RV of PE2.0. Histological analysis revealed massive accumulation of neutrophils (selective esterase stain) and monocyte/macrophages (CD68, ED-1) in RV of PE2.0 hearts in regions of myocyte damage. Electron microscopy showed myocyte necrosis and phagocytosis by inflammatory cells. LV function was normal and did not show increased inflammation after PE2.0. Treatment with anti-PMN antibody reduced RV MPO activity and prevented RV dysfunction. Conclusions-PE with moderately severe pulmonary hypertension (PE2.0) resulted in selective RV dysfunction, which was associated with increased chemokine expression, and infiltration of both neutrophils and monocyte/macrophages, indicating that a robust immune response occurred with RV damage following experimental PE. Experimental agranulocytosis reduced RV, suggesting that neutrophil influx contributed to RV damage.     

Pulmonary septic embolism with right side infectious endocarditis and ventricular septal defect: a case report

An 18-year-old man was diagnosed with ventricular septal defect after birth. He was asymptomatic until February 2006. He came to our hospital with remittent fever persisting for 2 months. Chest computed tomography showed multiple infiltrative shadows and alpha-streptococcus was detected on blood cultures. Transesophageal echocardiography detected vegetation (1.3 cm) on the right ventricle wall at the point of impact of the shunted bloodstream. We diagnosed pulmonary septic embolism and began to administer penicillin G and gentamicin. Sixteen days later, a new pulmonary septic embolism appeared, so antibiotic treatment was continued at a higher dose. Two weeks later, the vegetation and infiltrative shadow disappeared. Echocardiography showed the ratio of pulmonary to systemic blood flow was 1.2. These findings indicate that patch closure of ventricular septal defect may be necessary for prevention of recurrence of right side infectious endocarditis.     

Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction

OBJECTIVES: The purpose of this study was to evaluate the prevalence and diagnostic utility of cardiac troponin I to identify patients with right ventricular (RV) dysfunction in pulmonary embolism. BACKGROUND: Right ventricular overload resulting from elevated pulmonary resistance is a common finding in major pulmonary embolism. However, biochemical markers to assess the degree of RV dysfunction have not been evaluated so far. METHODS: In this prospective, double-blind study we included 36 study patients diagnosed as having acute pulmonary embolism. RESULTS: Among the whole study population, 14 patients (39%) had positive troponin I tests. Ten of 16 patients (62.5%) with RV dilatation had increased serum troponin I levels, while only 4 of 14 patients (28.6%) with elevated troponin I values had a normal RV diameter as assessed by echocardiography, indicating that positive troponin I tests were significantly associated with RV dilatation (p = 0.009). Patients with positive troponin I tests had significantly more segmental defects in ventilation/perfusion lung scans than patients with normal serum troponin I (p = 0.0002). CONCLUSIONS: Our data demonstrate that more than one-third of patients clinically diagnosed as having pulmonary embolism presented with elevated serum troponin I concentrations. Troponin I tests helped to identify patients with RV dilatation who had significantly more segmental defects in lung scans. Thus, troponin I assays are useful to detect minor myocardial damage in pulmonary embolism.