ECHOCARDIOGRAM IN THE EVALUATION AND MANAGEMENT OF PULMONARY EMBOLISMNandan Prasad

PGY-1

December 14, 2015

Questions

• What are echo findings in the presence of PE?• Can echo be used to diagnose PE?• Can echo be used to predict prognosis in the setting of PE?

• Can echo be used to guide management in the setting of PE?

Echo Findings• In hemodynamically significant PE, underfilled and hyperdynamic

left ventricle• Right ventricular dilation with > 1:1 RV/LV ratio• Right ventricular reduced function or contractility• McConnell’s sign – RV hypokinesis with spared apical function

and contraction• Tricuspid regurgitation• Pulmonary hypertension (peak tricuspid regurgitation jet velocity

>2.6 m/s)• Interventricular septum flattening and paradoxical motion toward

the LV (D-shaped septum)• IVC dilation without inspiratory collapse• Occasionally may see free floating thrombus in right heart or

pulmonary artery

RV Dilation

McConnell’s Sign

• RV hypokinesis with spared apical function and contraction

• McConnell et al• Retrospective study of 126 patients with PE underwent

echo with analysis for patterns of RV wall motion abnormalities

• 77% sensitivity, 94% specificity for pulmonary embolism

Interventricular Septum flattening (D-shape)

Right Heart Thrombus

Can Echo Be Used to Diagnose PE?

Echo For PE Diagnosis

• Bova et al (Am J Emerg Med 2003)

• 162 patients with suspected PE in the Emergency Department

• 68 had PE• RV dilation (65 patients) – specificity 94%, sensitivity

31%• Max. tricuspid regurgitation velocity above 2.7 m/s (55

patients) – 88% specificity, 51% sensitivity• Both findings present (55 patients) – 96% specificity,

29% sensitivity

Echo For PE Diagnosis• Mansencal et al (Echocardiography 2008)

• 76 patients with high clinical probability and positive D-Dimer in the Emergency Department

• All underwent CTA, echo and lower extremity ultrasound• 32 had actual PE based on CTA

• 17 had RV dilation• 18 had DVT• 8 had both

• Combined ultrasound (DVT + Echo) had sensitivity of 87% and specificity of 69%

Can echo be used for prognosis in the setting of PE?

Echo for PE prognosis• Riberio et al (Am Heart J 1997)

• 126 patients with PE underwent echo on the day of diagnosis• Moderate to severely reduced RV function – 1-year mortality 15.1%

vs 7.9% in those with normal or slightly reduced RV function (p = 0.04)

• Goldhaber et al (Lancet 1999)

• 1135 patients with PE underwent echo• 454 had RV hypokinesis

• RV hypokinesis higher mortality at 2 weeks and at 3 months• Hazard ratio was 2.0 (95% CI 1.3 – 2.9)

• findings strongly support the use of echocardiography to help risk stratify patients with PE

Echo for PE prognosis• ten Wold et al (Arch Intern Med 2004)

• Literature review of 5 studies including 1773 patients• Showed at least a 2-fold higher risk of dying in the short term when

RV dysfunction was present• Absolute difference in risk ranged from 4% to 18%

Echo for PE prognosis•  Konstantinides et al (Circulation 1997)

• Retrospective study of 719 patients with PE• Patients with hypotension on presentation and shock were

excluded• 552 underwent echo; 380 had evidence of RV dilation• 30-day mortality was 10% in these patients as opposed to 4.1% in

those without a dilated RV (P=.018).

Echo for PE prognosis• Grifoni et al (Circulation 2000)

• 209 patients with PE underwent echo in the Emergency Department

• Patients placed into groups based on hemodynamic stability and echo findings of RV strain

• Normotensive patients without RV strain did better than normotensive patients with RV strain• The only hemodynamically stable patients that had adverse events due

to PE also had evidence of RV strain on initial echo• Death rate in normotensive patients with RV strain was 5% (95% CI 0 to

13%), rate in normotensive patients with no RV strain was 0% (95% CI 0 to 4%)

Echo for PE prognosis• Sanchez et al (Eur Heart J 2008)

• Literature review of 12 studies that investigated findings of RV dysfunction and outcomes using either echo or CT in patients with hemodynamically stable PE

• 5 studies used echo to evaluate RV function in by various departments (ICU, ED, Cardiology)

• 221 patients with RV dysfunction had 21 adverse events vs 264 patients with normal RV function had 8 adverse events RR 2.5 (95% CI 1.2-5.5)

Echo for PE Prognosis• Fremont et al (Chest 2008)

• Study aimed to established an RV/LV end-diastolic diameter ratio as a prognostic factor

• Retrospective study of 950 patients hospitalized with PE who underwent echo and had a RV/LV ratio determined with outcome of hospital mortality

• Hospital mortality when RV/LV ratio ≥ 0.9 was 6.6% vs 1.9% when ≤ .9• Odds ratio 2.7 (95% CI 1.7 to 6.0)

• Conclusion: RV/LV ratio ≥ 0.9 was an independent predictive factor for hospital mortality

Echo for PE Prognosis• Kjaergaard et al (Euro J Echocardiography 2009)

• Propestictive study of 283 patients with PE underwent echo and follow up 1 year later with measurements of RV size, function and pressure

• Shortening of the pulmonary artery (PA) acceleration time (a measure of RV after-load) was associated with increased mortality (hazard ratio .084 per 10 ms increase, P < 0.0001)

• RV/LV diameter ratio was not found to be significantly correlated with all-cause mortality

Can Echo guide therapy in the setting of PE?

Echo for PE therapy • Goldhaber et al (Lancet 1993)

• Randomized trial• 101 patients with PE enrolled and followed for 14 days• 46 got tPa followed by heparin, 55 got heparin• 5 patients in heparin group had recurrent PEs, 2 of which were

fatal• All 5 had echo findings with RV hypokinesis

• Based on this study the authors recommended considering tPA in hemodynamically stable patients with signs of RV dysfunction

Echo for PE therapy •  Konstantinides et al (Circulation 1997)

• Retrospective study of 719 patients with PE who underwent heparinization and/or thrombolytics measuring 30 day mortality

• Patients with hypotension on presentation and shock were excluded

• 552 underwent echo; 441 had RV overload• right ventricular enlargement on echo associated with mortality rate

of 4.7% in the thrombolysis group compared with 11.1% in the heparin group (P=.16).

• Overall the thrombolytic group had decreased 30-day mortality that was statistically significant: OR .46 (95% CI .21 – 1.00)

Echo for PE therapy • Hamel et al (Chest 2001)

• Retrospective study of 153 hemodynamically stable patients with massive PE treated with heparin or thrombolytics

• All patients had confirmed PE and echocardiogram with right ventricular dilation defined as RV/LV diameter ratio > .6

• Found decreased deaths among those receiving heparin than those who received thrombolysis

Echo for PE Therapy• Stein et al (Amer J of Med 2008)

• Retrospective study of 76 patients from the PIOPED II trial with PE and RV enlargement treated with anticoagulants and/or IVC filters

• No difference in all-cause mortality compared to patients who did not have right ventricular enlargement

• -

Conclusions• Echocardiography cannot be used to rule out pulmonary

embolism, but can support the diagnosis when clinical suspicion is high

• There is strong evidence to suggest that echocardiography can help risk-stratify patients with PE in the setting of hemodynamic stability, either through RV/LV end-diastolic diameter ratio or pulmonary artery acceleration time

• There is no established evidence for use of echocardiogram to guide the decision to administer thrombolytics for submassive PE

References• A.J. Labovitz, V.E. Noble, M. Bierig, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography

and American College of Emergency Physicians. J Am Soc Echocardiogr, 23 (2010), pp. 1225–1230• 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;21:180-3• Donald Clark III, David C. McGiffin, Louis J. Dell’Italia, and Mustafa I. Ahmed. Circulation Cardiovascular Case Series:Submassive Pulmonary Embolism: Where’s the

Tipping Point? Circulation. 2013;127:2458-2464,doi:10.1161/CIRCULATIONAHA.112.000859• Fischer JI, Veld MA, Veld MA H i ‘t, Orland M, Harvey P, Panebianco NL, Dean AJ. Diagnosis of near-fatal pulmonary embolus-in-transit with focused

echocardiography. J Emerg Med. 2013;45(2):232–235. doi: 10.1016/j.jemermed.2013.03.015• Focused Emergency Echo, Part II. Dir. Chris L. Moore. SAEM Lecture Series. Academy of Emergency Ultrasound, n.d. Web. 13 Dec. 2015.• Fremont B, Pacouret G, Jacobi D, Puglisi R, Charbonnier B, de Labriolle A. Prognostic value of echocardiographic right/left ventricular end-diastolic diameter ratio in

patients with acute pulmonary embolism: results from a monocenter registry of 1,416 patients. Chest. 2008; 133: 358–362.• Goldhaber  SZVisani  LDe Rosa  M Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry

(ICOPER). Lancet.1999;3531386- 1389• Goldhaber, SZ, Haire, WD, Feldstein, ML, et al (1993) Alteplase versus heparin in acute pulmonary embolism: randomized trial assessing right-ventricular function and

pulmonary perfusion.Lancet341,507-511• Gregory Piazza and Samuel Z. Goldhaber. Clinician Update:Management of Submassive Pulmonary Embolism.

Circulation. 2010;122:1124-1129,doi:10.1161/CIRCULATIONAHA.110.961136• Grifoni, S, Olivotto, I, Cecchini, P, et al Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right

ventricular dysfunction.Circulation 2000;101,2817-2822• Hamel E, Pacouret G, Vincentelli D, et al. Thrombolysis Or Heparin Therapy In Massive Pulmonary Embolism With Right Ventricular Dilation*: Results From A 128-

Patient Monocenter Registry. Chest. 2001;120(1):120-125.• Kjaergaard J, Schaadt BK, Lund JO, Hassager C. Prognostic importance of quantitative echocardiographic evaluation in patients suspected of first non-massive

pulmonary embolism. Eur J Echocardiogr. 2009; 10: 89–95.• Konstantinides, S, Geibel, A, Olschewski, M, et al Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major

pulmonary embolism: results of a multicenter registry.Circulation1997;96,882-888• Mansencal N, Vieillard-Baron A, Beauchet A, Farcot J-C, El Hajjam M, Dufaitre G. Triage patients with suspected pulmonary embolism in the emergency department

using a portable ultrasound device. Echocardiography 2008;25:451-6.• M.V. McConnell, S.D. Solomon, M.E. Rayan, P.C. Come, S.Z. Goldhaber, R.T. Lee. Regional right ventricular dysfunction detected by echocardiography in acute

pulmonary embolism. Am J Cardiol, 78 (1996), pp. 469–473• M. P. Borloz, W. J. Frohna, C. A. Phillips, and M. S. Antonis, “Emergency department focused bedside echocardiography inmassive pulmonary embolism,” Journal of

Emergency Medicine, vol. 41, no. 6, pp. 658–660, 2011• Stein PD, Beemath A, Matta F, et al. Enlarged Right Ventricle Without Shock in Acute Pulmonary Embolism: Prognosis. The American journal of medicine.

2008;121(1):34-42. doi:10.1016/j.amjmed.2007.06.032.• Ribiero A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of

mortality rate. Am Heart J 1997;134:479-87• Sanchez O, Trinquart L, Colombet I, Durieux P, Huisman MV, Chatellier G, Meyer G. Prognostic value of right ventricular dysfunction in patients with haemodynamically

stable pulmonary embolism: a systematic review. Eur Heart J.2008; 29: 1569–1577• ten Wolde M, Söhne M, Quak E, Mac Gillavry MR, Büller HR. Prognostic Value of Echocardiographically Assessed Right Ventricular Dysfunction in Patients With

Pulmonary Embolism. Arch Intern Med.2004;164(15):1685-1689. doi:10.1001/archinte.164.15.1685.