J Cardiovasc Ultrasound.  2008 Mar;16(1):9-16. 10.4250/jcu.2008.16.1.9.

Role of Echocardiography in Patients with Acute Pulmonary Thromboembolism

• Lee JH
• Park JH

• KMID: 1486604
• DOI: http://doi.org/10.4250/jcu.2008.16.1.9

Abstract

Acute pulmonary thromboembolism (PTE) is a common problem. In the emergency room, a substantial number of patients with chest discomfort have had an acute PTE. Presently, accepted diagnostic modalities for the confirmation of PTE include ventilation/perfusion (V/Q) scanning, chest computed tomography (CT), and standard angiography. However, each modality has important limitations. Although chest CT scanning has for the most part replaced lung scanning as the main diagnostic test for PTE, transthoracic echocardiography (TTE) is a noninvasive modality providing rapid results at the bedside. As well as being noninvasive modality, TTE avoids the contrast and radiation hazards of chest CT or conventional angiography. Thus echocardiography is an attractive imaging modality to diagnose PTE. TTE allows visualization of the aorta and the LV to evaluate for other etiologies of chest pain. Besides giving important diagnostic information, TTE can aid prediction of prognosis. Presence of RV dilatation and dysfunction is a poor prognostic sign and is the indicator for thrombolytic therapy. However, TTE has some limitations including poor imaging quality depending on the acoustic window and has a low sensitivity in detecting PTE.

Keyword

Echocardiography; Transthoracic; Diagnosis; Pulmonary thromboembolism

MeSH Terms

Acoustics
Angiography
Aorta
Chest Pain
Diagnostic Tests, Routine
Dilatation
Echocardiography
Emergencies
Humans
Lung
Prognosis
Pulmonary Embolism
Thorax
Thrombolytic Therapy

Figure

• 

  Fig. 1 Characteristic features of acute pulmonary thromboembolism identified by transthoracic echocardiography. Right ventricular dilatation and dysfunction were seen in a patient with acute pulmonary thromboembolism. In the diastole, the ratio of the right ventricular end-diastolic area to left ventricular end-diastolic area was more than 1.0 which is consistent with severe right ventricular dysfunction (normal value is less than 0.6).

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  Fig. 2 Systolic and diastolic images with a parasternal short axis view from a patient with an acute pulmonary thromboembolism revealing septal flattening (D-shaped left ventricle) consistent with right ventricular pressure overload.

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  Fig. 3 McConnell's sign. Regional wall thickening fractions (mean±standard deviation) were presented in normal patients, patients with primary pulmonary hypertension (PPH), and those with a PTE. While apical wall motion was reduced in the PPH patients, it was intact in PTE patients. (Figure from McConnell MV, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996;78:469-73).

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  Fig. 4 Free-floating thrombi were found by transthoracic echocardiographic exam in a patient with acute pulmonary thromboembolism. A. A huge thrombus (arrows) was seen in the right atrium extended to right ventricle and crossing the tricuspid valve. B. After the opening of the right atrial wall, a worm like thrombus was found in the right atrium.

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  Fig. 5 Doppler tissue images of the right ventricular (RV) free wall were obtained using a low parasternal view, and three segments (apex, midventricle and base) were evaluated with an offset length of 12 mm. Baseline analysis showed decreased strain of the midventricle of the RV (A). Follow-up analysis showed increased strain of the midventricle with treatment (B). (Park JH, et al. Int J Cardiol 2008;125:319-24.)

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  Fig. 6 A proposed algorithm of diagnosis and care for patient with an acute pulmonary thromboembolism (PTE). Imaging modality in the bracket is optional according to the clinical situation. PEx: physical examination, CXR: chest X-ray, ECG: electrocardiography, VQ: ventilation/perfusion scan, MR: magnetic resonance imaging, PAgram: pulmonary ateriogram, RV: right ventricle, pro-BNP: pro B type natriuretic peptide, cTnT: cardiac troponin T, cTnI: cardiac troponin I.

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