Pulmonary embolism echocardiography

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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Rim Halaby, M.D. [2]

## Overview

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Routine echocardiography in patients with suspected pulmonary embolism (PE) is not required.[1] In fact, the majority of patients with PE have a normal echocardiography.[1] However if elevations in the cardiac troponins or brain natriuretic peptide are present, then acute right ventricular (RV) dysfunction may be present and echocardiography is warranted.[2] Echocardiography is also valuable for the evaluation of hemodynamically unstable patients with acute dyspnea, right heart failure, or syncope who are suspected to have PE.[1] The presence of right ventricular dysfunction is a predictor of early death among patients with PE.[3] When evidence of RV dysfunction is present, PE is risk stratified into submassive PE or massive PE depending on the absence or presence of hypotension respectively.[4][5]

## Echocardiography

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* In massive and submassive PE, RV dysfunction seen on echocardiography may indicate that the pulmonary artery is severely obstructed and that the heart is unable to compensate. Some studies suggest that this finding may be an indication for thrombolysis. The presence of RV dysfunction is a predictor of early death among patients with PE.[3]

* Echocardiography findings that are indicative of RV dysfunction are mainly:[4][5]
* RV dilation (ratio of apical 4-chamber RV diameter to left ventricle (LV) diameter > 0.9)
* RV systolic dysfunction

* Other echocardiographic findings that are supportive of the presence of RV dysfunction include:[1]
* Paradoxical intraventricular septal motion
* Tricuspid regurgitation
* Pulmonary artery hypertension (systolic pulmonary artery pressure over 30 mmHg)
* Patent foramen ovale (might occur when the pressure in the right atria is higher than that in the left atrium)

* Echocardiography may also show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The sensitivity and specificity of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.[6]

Shown below is an echocardiogram that demonstrates McConnell sign: {{#ev:youtube|Tklaxe-kPrk}}

* In addition, echocardiography findings that are associated with worse prognosis include:
* RV dysfunction[3]
* Right heart thrombus[7]
* Patent foramen ovale[8]

* Echocardiography should be used to confirm the presence of RV dysfunction if multidetector CT is not available.

## References

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1. ↑ 1.0 1.1 1.2 1.3 Goldhaber SZ (2002). "Echocardiography in the management of pulmonary embolism". Ann Intern Med. 136 (9): 691–700. PMID 11992305.
2. ↑ Kucher N, Goldhaber SZ (2003). "Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism". Circulation. 108 (18): 2191–4. doi:10.1161/01.CIR.0000100687.99687.CE. PMID 14597581.
3. ↑ 3.0 3.1 3.2 Goldhaber SZ, Visani L, De Rosa M (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218.CS1 maint: Multiple names: authors list (link)
4. ↑ 4.0 4.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter `|month=` ignored (help)
6. ↑ McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). "Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism". Am. J. Cardiol. 78 (4): 469–73. PMID 8752195.CS1 maint: Multiple names: authors list (link)
7. ↑ Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; et al. (2003). "Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry". J Am Coll Cardiol. 41 (12): 2245–51. PMID 12821255.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
8. ↑ Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H (1998). "Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism". Circulation. 97 (19): 1946–51. PMID 9609088. Retrieved 2011-12-21. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)

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