Quantitative Measures of Right Ventricular Dysfunction by Echocardiography in the Diagnosis of Acute Nonmassive Pulmonary Embolism

doi:10.1016/j.echo.2006.04.037

Journal of the American Society of Echocardiography

Volume 19, Issue 10, October 2006, Pages 1264-1271

https://doi.org/10.1016/j.echo.2006.04.037 Get rights and content

Background

Transthoracic echocardiography (TTE) is used in the risk assessment of patients with pulmonary embolism (PE), but the incremental diagnostic information from quantitative measures of right ventricular (RV) size, pressure, and function by TTE has yet to be fully evaluated.

Methods

In 300 consecutive patients with suspected first nonmassive PE, TTE and ventilation/perfusion scintigraphy were performed.

Results

Among measures of RV anatomy, RV pressure estimates, and estimates of global and regional RV function with significant diagnostic information in a logistic regression analysis, the acceleration time of RV outflow less than 89 milliseconds, the ratio of RV to left ventricular diameter greater than 0.78, RV outflow tract fractional shortening less than 35%, and signs of RV strain on electrocardiogram had independent, incremental diagnostic information (area under the receiver operating characteristics curve = 0.81). If D-dimer greater than 4.1 mmol/L was included, the area under the curve increased to 0.88. The negative and positive predictive values if any 2 of 3 factors in the final model were present were 88% and 70%, respectively.

Conclusion

TTE is able to identify differential diagnoses and enhance pretest probability of PE significantly. TTE could therefore be considered as an integral part of the initial diagnostic workup of patients suspected of PE, especially if definitive diagnostic imaging has limited availability.

Section snippets

Patients

The study population consisted of a consecutive series of clinically stable patients older than 18 years, referred for ventilation/perfusion (V/Q) scintigraphy scan to establish the diagnosis of first nonmassive PE. Among 321 patients eligible for inclusion, 21 refused to participate, leaving 300 patients (94%) able to provide informed consent for participation in the study. The study was approved by the local scientific ethical committee.

Among the 300 patients, V/Q scan was cancelled in 3

Results

Patients referred for V/Q scan were age 68 ± 16 years, range 19 to 97 years. In all, 150 patients (53%) were female and 133 (47%) were male. Thirteen V/Q scan results (4%) were of insufficient quality to allow firm interpretation, leaving 283 patients for further analysis. TTE and V/Q scan were performed within a median interval of 1.6 hours (maximal delay 5.6 hours). In all, 58 patients (20%) had PE on the V/Q scan, whereas 119 patients with indeterminate and 106 patient with normal scan

Discussion

Modern quantitative echocardiographic evaluation of RV size, systolic pressure, and function, in particular the RV/LV ratio, the PA acceleration time, and RVOT FS, are important parameters to consider when evaluating patients with suggested nonmassive PE.

However, the sensitivity and predictive values of the TTE parameters alone are too low to be an alternative to established imaging techniques for the final diagnosis of nonmassive PE. But, when adding the echocardiographic information to

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ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update
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Although additional studies have focused on the accuracy of these findings on a practical basis, all patients for whom these findings are suggested—either for transesophageal or transthoracic echocardiography—will undergo CTPA to identify a filling defect in the diagnosis of PE [51]. Risk stratification for right ventricular failure when there is a positive CTPA [52-57] is commonly used, but this clinical situation (after a diagnosis of PE) is not within the scope of this document. Literature suggests that PE can be suspected during echocardiography when there is a hypo- or akinetic mid and basal right ventricular free wall associated with a seemingly normal or hyperkinetic right ventricular apical wall motion [50].
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Summary: Lung ultrasound is a useful point-of-care investigation in acute care, especially in patients with dyspnoea or haemodynamic instability. Although normal lung parenchyma is not accessible to ultrasound, distinctive artefacts arising from parietal and visceral pleura indirectly imply the presence of normal lung. As aeration of lung tissue reduces with disease process, visual assessment of several pathologic entities by ultrasound becomes possible. Ultrasound can be used for qualitative and quantitative assessment as well as to guide intervention. Compared with supine anteroposterior chest x-rays, lung ultrasound is faster and superior at ruling out pneumothorax and diagnosing lung consolidation, pleural effusions or pulmonary oedema. It is a logical and highly valuable extension of echocardiography and can be incorporated into diagnostic algorithms for assessment of dyspnoea, hypotension, chest pain or trauma. It provides rapid information about potentially reversible pathology in cardiac arrest scenarios. Other advantages include bedside availability, repeatability, provision of dynamic diagnostic information, ease of use and the absence of radiation exposure.
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Our systematic search strategy yielded 5,905 articles without duplicates (7,164 total). Of these, 464 were selected for full text review and 21 were deemed to meet all inclusion criteria and no exclusions for this review (Figure 1 and Table 1).23-46 The percent agreement between the two reviewers for article selection was 94.3%, and Cohen’s kappa was κ = 0.908 (95% CI, 0.836–0.980; P < .001).
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: Supported by a research fellowship from the Danish Heart Foundation, grant No. 03-2-3-46A-22112 (Dr Kjaergaard).

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Original articleQuantitative Measures of Right Ventricular Dysfunction by Echocardiography in the Diagnosis of Acute Nonmassive Pulmonary Embolism

Background

Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Am J Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

Ann Emerg Med

Int J Cardiol

Am J Cardiol

Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism

N Engl J Med

Cross sectional Doppler echocardiography as the initial technique for the diagnosis of acute pulmonary embolism

Br Heart J

Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism

Eur Heart J

Prospective evaluation of two-dimensional transthoracic echocardiography in emergency department patients with suspected pulmonary embolism

Acad Emerg Med

Right ventricular outflow-tract fractional shortening: an applicable measure of right ventricular systolic function

Eur J Echocardiogr

Original article
Quantitative Measures of Right Ventricular Dysfunction by Echocardiography in the Diagnosis of Acute Nonmassive Pulmonary Embolism