Echocardiographic Pattern of Acute Pulmonary Embolism: Analysis of 511 Consecutive Patients

      Background

      There is no comprehensive analysis of transthoracic echocardiographic findings of pulmonary embolism (PE). The aim of this study was to assess the frequency of right ventricular (RV) dysfunction (RVD), typical echocardiographic signs of acute PE (TES), and incidental abnormalities.

      Methods

      A single-center, retrospective analysis was conducted of 511 consecutive patients (281 women; mean age, 64.0 ± 18.6 years) with PE confirmed by contrast-enhanced multidetector computed tomography who underwent transthoracic echocardiography for the assessment of left ventricular and RV alterations. The McConnell sign, the “60/60” sign, and right heart thrombus were regarded as TES. RVD included RV free wall hypokinesis and RV to LV end-diastolic ratio > 0.9. Incidental echocardiographic alterations were also reported.

      Results

      RV enlargement, RV free wall hypokinesis, and interventricular septal flattening were found in 27.4%, 26.6%, and 18.4% of patients, respectively. Tricuspid regurgitation peak systolic gradient > 30 mmHg and pulmonary ejection acceleration time < 80 msec were measured in 46.6% and 37.2% of patients, respectively. RVD was found in 20.0% of patients, while normal RV function was present in 33.4% of patients. The McConnell sign, 60/60 sign, and right heart thrombus were found in 19.8%, 12.9%, 1.8% of subjects, respectively. All 16 hemodynamically unstable patients with PE presented enlarged hypokinetic right ventricle and at least one TES. However, in three of them, RV to LV end-diastolic ratio was <0.9. Incidental abnormalities were found in 9.6% of 364 stable patients with PE without RVD and TES.

      Conclusions

      Transthoracic echocardiography showed no significant abnormalities suggestive of PE in 71% of patients with PE, while in approximately 10%, transthoracic echocardiography revealed incidental findings. The coexistence of an enlarged hypokinetic right ventricle with the McConnell sign together with the 60/60 sign seems to be the most useful echocardiographic criterion for RVD.

      Keywords

      Abbreviations:

      AcT (Pulmonary ejection acceleration time), AR (Aortic regurgitation), AS (Aortic stenosis), AVA (Aortic valve area), EROA (Effective regurgitant orifice area), IVC (Inferior vena cava), LV (Left ventricle), MR (Mitral regurgitation), PE (Pulmonary embolism), RV (Right ventricle), RVD (Right ventricular dysfunction), TES (Typical echocardiographic signs of acute pulmonary embolism), TR (Tricuspid valve regurgitation), TRPG (Tricuspid regurgitation peak systolic gradient), TTE (Transthoracic echocardiography), VC (Vena contracta)
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      References

        • Konstantinides S.
        • Torbicki A.
        • Agnelli G.
        • Danchin N.
        • Fitzmaurice D.
        • Galiè N.
        • et al.
        2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) endorsed by the European Respiratory Society (ERS).
        Eur Heart J. 2014; 35 (Authors/Task Force Members): 3033-3080
        • Jardin F.
        • Dubourg O.
        • Gueret P.
        • Delorme G.
        • Bourdarias J.P.
        Quantitative two-dimensional echocardiography in massive pulmonary embolism: emphasis on ventricular interdependence and leftward septal displacement.
        J Am Coll Cardiol. 1987; 10: 1201-1206
        • Pruszczyk P.
        • Goliszek S.
        • Lichodziejewska B.
        • Kostrubiec M.
        • Ciurzynski M.
        • Kurnicka K.
        • et al.
        Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism.
        JACC Cardiovasc Imaging. 2014; 7: 553-560
        • Khemasuwan D.
        • Yingchoncharoen T.
        • Tunsupon P.
        • Kusunose K.
        • Moghekar A.
        • Klein A.
        • et al.
        Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism.
        J Am Soc Echocardiogr. 2015; 28: 355-362
        • McConnell M.V.
        • Solomon S.D.
        • Rayan M.E.
        • Come P.C.
        • Goldhaber S.Z.
        • Lee R.T.
        Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism.
        Am J Cardiol. 1996; 78: 469-473
        • Torbicki A.
        • Kurzyna M.
        • Ciurzynski M.
        • Pruszczyk P.
        • Pacho R.
        • Kuch-Wocial A.
        • et al.
        Proximal pulmonary emboli modify right ventricular ejection pattern.
        Eur Respir J. 1999; 13: 616-621
        • Kurzyna M.
        • Torbicki A.
        • Pruszczyk P.
        • Burakowska B.
        • Fijalkowska A.
        • Kober J.
        • et al.
        Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism.
        Am J Cardiol. 2002; 90: 507-511
        • Torbicki A.
        • Galie N.
        • Covezzoli A.
        • Rossi E.
        • De Rosa M.
        • Goldhaber S.Z.
        • et al.
        Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry.
        J Am Coll Cardiol. 2003; 41: 2245-2251
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • Hua L.
        • Handschumacher M.D.
        • Chandrasekaran K.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Vahanian A.
        • Alfieri O.
        • Andreotti F.
        • Antunes M.J.
        • Baron-Esquivias G.
        • Baumgartner H.
        • et al.
        Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur J Cardiothorac Surg. 2012; 42: S1-S44
        • Lancellotti P.
        • Tribouilloy C.
        • Hagendorff A.
        • Popescu B.A.
        • Edvardsen T.
        • Pierard L.A.
        • et al.
        Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2013; 14: 611-644
        • Jaff M.R.
        • McMurtry M.S.
        • Archer S.L.
        • Cushman M.
        • Goldenberg N.
        • Goldhaber S.Z.
        • et al.
        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. 2011; 123: 1788-1830
        • McMurray J.J.V.
        • Adamopoulos S.
        • Anker S.D.
        • Auricchio A.
        • Böhm M.
        • Dickstein K.
        • et al.
        ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC.
        Eur Heart J. 2012; 33 (Authors/Task Force Members): 1787-1847
        • Müller R.
        • Büttner P.
        A critical discussion of intraclass correlation coefficients.
        Stat Med. 1994; 13: 2465-2476
        • Le Gal G.
        • Righini M.
        • Roy P.M.
        • Sanchez O.
        • Aujesky D.
        • Bounameaux H.
        • et al.
        Prediction of pulmonary embolism in the emergency department: the revised Geneva score.
        Ann Intern Med. 2006; 144: 165-171
        • Perrier A.
        • Tamm C.
        • Unger P.F.
        • Lerch R.
        • Sztajzel J.
        Diagnostic accuracy of Doppler-echocardiography in unselected patients with suspected pulmonary embolism.
        Int J Cardiol. 1998; 65: 101-109
        • Kasper W.
        • Meinertz T.
        • Henkel B.
        • Eissner D.
        • Hahn K.
        • Hofmann T.
        • et al.
        Echocardiographic findings in patients with proved pulmonary embolism.
        Am Heart J. 1986; 112: 1284-1290
        • Bova C.
        • Greco F.
        • Misuraca G.
        • Serafini O.
        • Crocco F.
        • Greco A.
        • et al.
        Diagnostic utility of echocardiography in patients with suspected pulmonary embolism.
        Am J Emerg Med. 2003; 21: 180-183
        • Miniati M.
        • Monti S.
        • Pratali L.
        • Di Ricco G.
        • Marini C.
        • Formichi B.
        • et al.
        Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients.
        Am J Med. 2001; 110: 528-535
        • Jardin F.
        • Dubourg O.
        • Bourdarias J.P.
        Echocardiographic pattern of acute cor pulmonale.
        Chest. 1997; 111: 209-217
        • Chartier L.
        • Bera J.
        • Delomez M.
        • Asseman P.
        • Beregi J.P.
        • Bauchart J.J.
        • et al.
        Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.
        Circulation. 1999; 99: 2779-2783
        • Casazza F.
        • Bongarzoni A.
        • Capozi A.
        • Agostoni O.
        Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction.
        Eur J Echocardiogr. 2005; 6: 11-14
        • Vitarelli A.
        • Barilla F.
        • Capotosto L.
        • D'Angeli I.
        • Truscelli G.
        • De Maio M.
        • et al.
        Right ventricular function in acute pulmonary embolism: a combined assessment by three-dimensional and speckle-tracking echocardiography.
        J Am Soc Echocardiogr. 2014; 27: 329-338
        • Konstantinides S.
        • Goldhaber S.Z.
        Pulmonary embolism: risk assessment and management.
        Eur Heart J. 2012; 33: 3014-3022