Teaching points
Introduction
Differences in the right and left heart
Acute pulmonary embolus and right ventricular compromise
Differences in massive and submassive PE
PE subtypes | Massive PE | Submassive PE | Simple PE |
---|---|---|---|
% of PE patients | ≈ 5% | ≈ 40% | ≈ 55% |
Clinical definition | Sustained hypotension (systolic < 90 mmHg for at least 15 min), need for inotropic support, persistent profound bradycardia (HR < 40 bpm with signs or symptoms of shock) | Systemically normotensive (systolic BP > 90 mmHg), myocardial ischemia (elevated troponins, ECG changes), and/or RV dysfunction (dysmotility on Echo, Increased RV/LV ratio > 0.9, elevated BNP/pro BNP), ECG changes) | Systemically normotensive (systolic BP > 90 mmHg), no RV dysfunction, no myocardial ischemia |
Mortality | 18–65% | 5–25% | Up to 1% |
Clinical considerations in acute PE and RV compromise
Chronic thromboembolic pulmonary hypertension
CTEPH and right ventricular compromise
Clinical considerations in CTEPH
Modality | Findings |
---|---|
Echocardiogram | • PAP > 25 mmHg • Right atrial and right ventricular dilatation • Reduced right ventricular contractility |
Nuclear medicine studies | • Segmental wedge-shaped mismatched defects on perfusion scan |
Right heart catheterization | • PAP is ≥ 25 mmHg • Pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg • Pulmonary vascular resistance is > 240 dyn-sec-cm-5 |
Invasive and noninvasive pulmonary angiogram | Invasive: • Stenoses and occlusions Noninvasive: • Bands, webs, stenoses, and occlusions |
Dual energy CT | CTA portion of study: • Bands, webs, stenoses, and occlusions Perfusion blood volume of study • Decreased perfusion in regions of involvement |