Regional right ventricular strain pattern in patients with acute pulmonary embolism

Aims: Right ventricular (RV) dysfunction is a frequent consequence of pulmonary embolism (PE) and a marker of increased risk. However, current qualitative methods assessing RV function are imprecise. We sought to determine whether RV strain analysis would have clinical utility in patients with PE compared with normal controls. Methods and results: We compared 75 acute PE subjects (mean age 54 ± 16) with 30 normal controls (mean age 50 ± 15). Regional RV longitudinal strain was assessed using offline speckle tracking software to obtain strain and strain rate data from the basal, mid, and apical free wall and septum. Global RV free wall and septal strain was significantly reduced in PE subjects (?14.17 (±5.96) vs ?24.92 (±4.16), P < 0.0001; ?14.99 (±5.55) vs ?18.54 (±7.34), P = 0.0082). Regional RV strain was markedly reduced in PE subjects in all regions of the free wall and in the mid and basal septum (P < 0.05). Strain rates of PE subjects were significantly reduced in all segments of the RV free wall (P < 0.05). In 36 PE subjects with regional RV dysfunction (“McConnell sign”), strain in the apical free wall was significantly reduced in comparison to those without (?10.08 vs ?13.51; P = 0.0420), in parallel with higher RV:LV ratios (1.30, ±1.01 vs 0.78, ±0.16; P = 0.0035) and lower RV fractional area change (32.06, ±14.42 vs 42.52, ±11.61; P = 0.0021). Conclusions: Regional RV longitudinal strain is altered in the free wall and mid and basal septum in subjects with acute PE. Strain rates are only reduced in the RV free wall. (Echocardiography 2012;29:464‐470)     

急性肺栓塞患者右室功能不全与肺血流灌注的相关性

目的观察血压正常的急性肺栓塞患者右室超声心动指标与肺血管阻塞严重程度相关性及治疗有效性的预测价值。方法回顾我院6年间收治的56例血压正常的急性肺栓塞患者的临床资料,分析其超声心动图所测得的右室收缩末期及舒张末期面积与肺灌注扫描灌注缺损数和增强螺旋CT所代表的肺血管阻塞之间的相关性。结果与正常对照相比,肺栓塞患者右室舒张末面积和收缩末面积增大,且与肺灌注缺损数呈正相关（r=0.76,P<0.01;r=0.77,P<0.01）,而舒张与收缩末面积的变化率则降低,与肺灌注缺损数呈负相关（r=-0.44,P<0.01）。增强CT显示血管阻塞越广泛,收缩末面积越大（P<0.05）,舒张与收缩末面积的变化率越小（P<0.05）。治疗有效时,肺灌注缺损数随右室功能的好转而降低。结论血压稳定的急性肺栓塞患者右室功能的异常程度与肺血管的阻塞程度密切相关,右室功能的检查可用于观察肺灌注情况以及治疗有效情况的相关指标。     

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。     

Isolated right ventricular noncompaction caused ventricular tachycardia and pulmonary embolism

Isolated ventricular noncompaction is an unclassified cardiomyopathy due to intrauterine arrest of compaction of the loose interwoven meshwork. Its mortality and morbidity are high, including heart failure, thromboembolic events, and ventricular arrhythmias. Isolated right ventricular noncompaction was reported rarely, especially that causes pulmonary embolism and ventricular tachycardia. We describe a case of isolated noncompaction of the right ventricular causing pulmonary embolism and ventricular tachycardia.     

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.     

急性肺栓塞57例心电图变化与分析

目的 探讨急性肺栓塞的心电图变化特点.方法 对57例确诊急性肺栓塞患者的心电图进行回顾性分析.结果 心动过速45例（78.9％）,其中房性期前收缩、房性心动过速8例,心房纤颤6例,ST-T改变41例（71.9％）,Tv1-Tv3倒置33例（57.9％）,Tv1-Tv4均倒置25例（43.9％）,avR导联R波升高30例（52.6％）,顺钟向转位25例（43.8％）,电轴右偏20例（35.1％）,右心室高电压16例（28.1％）,典型SIQⅢTⅢ 15例（26.3％）,肺型P波15例（26.3％）,右束支传导阻滞9例（15.7％）：其中完全性右束支传导阻滞2例,不完全性右束支传导阻滞7例.部分患者具有以上多项心电图改变.结论 急性肺栓塞心电图表现复杂多变,临床医生应细心观察心电图变化,结合临床,重视高危因素,即可在一定程度上减少漏诊误诊的发生,对急性肺栓塞的诊断和治疗具有重要意义.     

Usefulness of right ventricular strain assessment in submassive pulmonary thromboembolism undergoing ultrasound‐facilitated thrombolysis

Massive and submassive pulmonary thromboembolism carry significant morbidity and mortality. We present an elderly female who was diagnosed with a submassive pulmonary embolism by computed tomographic angiography and treated with ultrasound‐facilitated thrombolysis (UFT). This case demonstrates the usefulness of right ventricular longitudinal strain measurements by two‐dimensional speckle tracking echocardiography in the evaluation of right ventricular function before and after UFT. Evaluation of right ventricle longitudinal strain by speckle tracking echocardiography may supplement other parameters in the assessment of right ventricular function in these patients.     

Diagnostic yield of CT pulmonary angiography for pulmonary embolism in clinically suspected patients

Pulmonary embolism (PE) is a common medical problem. Its diagnostic criteria must be reviewed to determine the need for confirmatory testing. Computed tomography pulmonary angiography (CTPA) is the current standard of care, which provides accurate diagnosis with rapid turnaround. This study aimed to estimate the diagnostic yield of CTPA in clinically suspected PE patients in a tertiary care hospital in Saudi Arabia.Radiology records of all patients with clinically suspected PE who underwent CTPA between January 1, 2012 and September 30, 2018 were reviewed retrospectively. A radiologist with 10 years of professional experience interpreted and reported all cases. The Wells score with 2 tiers (likely and unlikely) was used to raise the clinical suspicion of PE.Positive results for PE were reported in 177 out of 534 clinically suspected cases (33%). Among the positive PE cases, 143 were acute (81%) and 34 (19%) were chronic. Bilateral, right-sided, and left-sided PE were found in 115 (65%), 37 (21%), and 25 (14%) cases, respectively. Involvement of the segmental branches, subsegmental branches, and the pulmonary trunk were noted in 152 (86%), 70 (40%), and 9 cases (5%), respectively. Saddle PE was found in (4%) of the cases. The lower lobe branches (right 55%, left 53%) and the upper lobe branches (right 47%, left 41%) were the most common sites of involvement.CTPA had a higher positive detection rate for PE among clinically suspected cases than its published diagnostic yield. Adequate clinical evaluation when selecting patients for CTPA is emphasized to minimize unjustified exposure of the patients to radiation and intravenous contrast administration. It is crucial for radiologists to provide detailed reports commenting on all relevant findings, including pertinent negatives. A template for reporting radiological findings for CTPA can be recommended for this purpose.     

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.     

Acute right ventricular infarction secondary to massive pulmonary embolism

Isolated right ventricular infarction has been found in casesof right ventricular hypertrophy, but there are no reports onright ventricular infarction secondary to massive pulmonaryembolism. Six autopsied patients with massive pulmonary embolismand pure right ventricular infarction, suspected to be secondaryto the embolism, were selected from a population of 216 autopsies.Pulmonary embolism was the suspected diagnosis in five casesdue to typical clinical, electrocardiographic and haemodynamicdata. Right ventricular infarction was a post-mortem finding,not previously diagnosed. In every case the thickness of theright ventricular myocardium was normal. The necrosis of theright ventricle was transmural in four cases and subendcardialin two and the entire right ventricular wall (anterolateralas well as posterior) was involved. No mural thrombi were presentand in no case did the necrosis involve the left ventricle.In one case the coronary arteries were normal, in the otherfive significant lesions of the right or the left coronary arterieswere observed. These lesions may have been, in part, responsiblefor the necrosis of the right ventricle when the massive pulmonaryembolism was added. We conclude that right ventricular infarctionmay be secondary to pulmonary hypertension in the setting ofmassive pulmonary embolism, even in the absence of right ventricularhypertrophy and with normal or stenotic coronary arteries.     

组织多普勒成像对慢性肺动脉高压患者右心室功能的评价

目的 探讨组织多普勒成像技术评价慢性肺动脉高压患者右心室功能及与肺动脉收缩压的关系.方法 对2006年10月至2007年3月在复旦大学华山医院心内科就诊的35例慢性肺动脉高压和35名正常人进行组织多普勒超声心动图检查,从心尖四腔观获得右室侧壁三尖瓣环的运动速度频谱图,测量收缩期S波峰速度(Sm),舒张早期负向E波峰速度(Em),舒张晚期负向A波峰速度(Am),等容收缩时间(IVCT)和等容舒张时间(IVRT).结果 肺动脉高压组Sm、Em和Em/Am均低于对照组,肺动脉高压组Am、IVRT均高于对照组,差异均有显著性意义.IVRT和肺动脉收缩压(PASP)存在显著的正相关(r=0.78,P＜0.01),IVRT≥60 ms诊断肺动脉高压的敏感度和特异度分别为83%和86%.结论 慢性肺动脉高压导致右心收缩及舒张功能减退,当连续多普勒不能估测肺动脉收缩压时,组织多普勒可作为肺动脉收缩压估测的新方法.     

CT肺栓塞指数在肺栓塞患者中的临床应用研究

目的:探讨肺栓塞指数(CTI)在肺栓塞(PE)患者中的临床应用价值。方法:入选通过双源CT肺动脉造影确诊的187例PE患者,132例为急性PE,55例为慢性PE;急性PE中,低危组46例,中危组86例,高危组0例。通过CT影像计算CTI,结合PE危险分层绘制两者的受试者工作曲线(ROC曲线)并得到最佳诊断阈值,按对应的CTI将急、慢性PE患者分别划分为2组,对比分析2组的临床病例资料。结果:1急性PE中,低危组平均CTI为(37.5±27.4)%,中危组平均CTI为(50.8±23.9)%,差异具有统计学意义(P0.05);慢性PE平均CTI为(23.1±21.9)%。2CTI与危险分层的ROC曲线下面积为0.653(P=0.004),最佳诊断阈值对应的CTI为60%。3急、慢性PE患者CTI在性别、年龄分布上的差异均无统计学意义。4急性PE中,与CTI60%组相比,CTI≥60%组出现呼吸困难及晕厥症状比例更多,心率更快,PaO_2、SaO_2、PaCO_2降低,P(A-a)O_2增高,WBC、NEUT、Hs CRP增高,cTnI、BNP、D-二聚体增高,RA、RV、RV/LV增高(均P0.05)。2组在收缩压、舒张压方面差异无统计学意义。5慢性PE中,与CTI60%组相比,CTI≥60%组出现呼吸困难症状比例更多,PaO_2、SaO_2、PaCO_2降低,P(A-a)O_2增高,HsCRP、D-二聚体增高,RA、RV、RV/LV增高。急性、慢性PE中,CTI≥60%组的肺栓塞严重指数(PESI)评分均高于CTI60%组(P0.05)。结论:CTI与PE危险分层具有显著的相关性,两者ROC曲线的最佳诊断阈值所对应的CTI为60%。以60%为界,CTI可良好区分急、慢性PE患者的病情严重程度及预后,说明CTI在急、慢性PE患者中均具有一定的临床应用价值。     

Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism

Background

Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown.

Methods

We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP.

Results

Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m^2, (0.88‐2.15 L/min/m²), to 2.5 L/min/m² (range 1.88‐3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79‐105), and mean systolic blood pressure increased to 140 mmHg (115‐179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge.

Conclusion

In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.

     

CHA2DS2‐VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism

BackgroundAccurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA₂DS₂‐VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation.HypothesisThis study aims to evaluate the association between CHA₂DS₂‐VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA).MethodsOne hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA₂DS₂‐VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA.ResultsPESI and CHA₂DS₂‐VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA₂DS₂‐VASc score and PESI score had a positive correlation. The area under the curve value for the CHA₂DS₂‐VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity.ConclusionThis study showed that not only CHA₂DS₂‐VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA₂DS₂‐VASc and PESI scores are able to predict RV dysfunction.