Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction

ArticleinEuropean Heart Journal – Cardiovascular Imaging 6(1):11-4 · February 2005with30 Reads
DOI: 10.1016/j.euje.2004.06.002 · Source: PubMed
Abstract
A normally contracting right ventricular apex associated to a severe hypokinesia of the mid-free wall ('McConnell sign') has been considered a distinct echocardiographic pattern of acute pulmonary embolism. To evaluate the clinical utility of the 'McConnell sign' in the bedside diagnostic work-up of patients presenting to the Emergency Department with an acute right ventricular dysfunction due to pulmonary embolism or right ventricular infarction. Among 201 patients, consecutively selected from our clinical database and diagnosed as having massive or submassive pulmonary embolism or right ventricular infarction, 161 were suitable for an echocardiographic review of regional right ventricular contraction and were included in the study. There were 107 cases with pulmonary embolism (group 1) and 54 cases with right ventricular infarction (group 2). All echocardiographic studies were randomly examined by two experienced and independent echocardiographers, blinded to the patient diagnosis and without Doppler informations. The McConnell sign was detected in 75 of 107 patients in group 1 (70%) and in 36 of 54 patients in group 2 (67%); the finding was absent in 32 cases in group 1 and in 18 cases in group 2 (P=0.657). The sensitivity, specificity, positive and negative predictive values of the McConnell sign for the diagnosis of pulmonary embolism were respectively 70, 33, 67 and 36%. In a clinical setting of patients with acute right ventricular dysfunction the McConnell sign cannot be considered a specific marker of pulmonary embolism.
    • "The McConnell sign, where good apical but poor free wall contraction is seen, is considered an important sign by some [46] . However, it is also found in right ventricular infarction and its specificity for pulmonary embolism has been called into question [47, 48]. The pulmonary artery systolic pressure is most commonly obtained by converting the peak velocity of the tricuspid regurgitation to pressure using the modified Bernoulli equation and adding to the right atrial pressure. "
    [Show abstract] [Hide abstract] ABSTRACT: Echocardiography is pivotal in the diagnosis and management of the shocked patient. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied. In the acute situation a basic study often yields immediate results allowing for the initiation of therapy, while a follow-up advanced study brings the advantage of further refining the diagnosis and providing an in-depth hemodynamic assessment. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography. A more comprehensive diagnosis can be achieved with advanced levels of competency, for which practice guidelines are also now available. Hemodynamic evaluation and ongoing monitoring are possible with advanced levels of competency, which includes the use of colour Doppler, spectral Doppler, and tissue Doppler imaging and occasionally the use of more recent technological advances such as 3D or speckled tracking. The four core types of shock—cardiogenic, hypovolemic, obstructive, and vasoplegic—can readily be identified by echocardiography. Even within each of the main headings contained in the shock classification, a variety of pathologies may be the cause and echocardiography will differentiate which of these is responsible. Increasingly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock or hypovolemia and ventricular outflow obstruction. The diagnostic benefit of echocardiography in the shocked patient is obvious. The increasing prevalence of critical care physicians experienced in advanced techniques means echocardiography often supplants the need for more invasive hemodynamic assessment and monitoring in shock.
    Full-text · Article · Dec 2016
    • "RVMI has previously been described as an etiology of RRVD [19]. In fact, Casazza et al. [20] estimated the specificity of RRVD for PE to be very low (33 %) when including RVMI patients. Although our study selection of patients referred for the three investigations (CTA, echocardiography and biomarkers) precludes a more general estimation of RRVD specificity, our 15-year study period shows that a diagnostic dilemma between acute RVMI and PE is rare, as no patient was found to have RVMI. "
    [Show abstract] [Hide abstract] ABSTRACT: Regional right ventricular (RV) dysfunction (RRVD) is an echocardiographic feature in acute pulmonary embolism (PE), primarily reported in patients with moderate-to-severe RV dysfunction. This study investigated the clinical importance of RRVD by assessing its relationship with clot burden and biomarkers. We identified consecutive patients admitted to the emergency department between 1999 and 2014 who underwent computed tomographic angiography, echocardiography, and biomarker testing (troponin and NT-proBNP) for suspected acute PE. RRVD was defined as normal excursion of the apex contrasting with hypokinesis of the mid-free wall segment. RV assessment included measurements of ventricular dimensions, fractional area change, free-wall longitudinal strain and tricuspid annular plane systolic excursion. Clot burden was assessed using the modified Miller score. Of 82 patients identified, 51 had acute PE (mean age 66 ± 17 years, 43 % male). No patient had RV myocardial infarction. RRVD was present in 41 % of PEs and absent in all patients without PE. Among patients with PE, 86 % of patients with RRVD had central or multi-lobar PE. Patients with RRVD had higher prevalence of moderate-to-severe RV dilation (81 vs. 30 %, p < 0.01) and dysfunction (86 vs. 23 %, p < 0.01). There was a strong trend for higher troponin level in PE patients with RRVD (38 vs. 13 % in PE patients without RRVD, p = 0.08), while there was no significant difference for NT-proBNP (67 vs. 73 %, p = 0.88). RRVD showed good concordance between readers (87 %). RRVD is associated with an increased clot burden in acute PE and is more prevalent among patients with moderate-to-severe RV enlargement and dysfunction.
    Full-text · Article · Oct 2015
    • "Pulmonary embolism was referred to be associated with the so-called McConnell sign showing a decrease in free wall contraction with preserved apical function [10]. However, it was demonstrated that the sign is not specific and may be seen also in patients with RV myocardial infarction [11]. In addition to measurements of left and right regional and global ventricular function, echocardiography allows a reasonably precise evaluation of cardiac output. "
    [Show abstract] [Hide abstract] ABSTRACT: Coronary artery disease (CAD) is one of the major causes of morbidity and mortality. Imaging techniques represent the key method for disease extent and severity assessment and evaluation of hemodynamic complications. In skilled hands the method provides useful information for clinical management and prognosis assessment. Complex evaluation brings information about global and regional myocardial function, myocardial viability, ischemic mitral regurgitation, and about development of complications such as left ventricular thrombus formation, myocardial rupture and pericardial effusion. The main drawback of echocardiography is the limited echogenicity of many patients and its undeniable operator-dependence. However, the possibility of bringing the echocardiographic imaging to the bedside of our patients makes the method essential and its knowledge indispensable for all cardiologists.
    Full-text · Article · Oct 2015
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