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Semin Respir Crit Care Med 2017; 38(01): 018-028
DOI: 10.1055/s-0036-1597563
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Echocardiography in the Risk Assessment of Acute Pulmonary Embolism

Talal Dahhan
1   Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina
,
Fawaz Alenezi
2   Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
,
Zainab Samad
2   Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
,
Sudarshan Rajagopal
2   Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
› Author Affiliations
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Publication History

Publication Date:
16 February 2017 (online)

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Abstract

Acute pulmonary embolism (PE) is a major cause of morbidity and mortality and is classified as massive (high risk), submassive (intermediate risk), or nonmassive (low risk) based on the hemodynamic status and clinical characteristics of the patient. At this time, the management of patients with submassive PE remains controversial and approaches for improving risk assessment are critical. In this review, we discuss several echocardiographic methods to assess right heart function that may aid in the risk assessment of patients with acute PE. They range from qualitative assessments of right ventricular (RV) function, such as subjective RV function and McConnell sign, to more recently developed quantitative parameters of RV function, such as tricuspid annular plane systolic excursion, RV/left ventricular ratio, and RV global and free wall longitudinal strain. Because of their reproducibility and objective nature, quantitative RV echocardiographic assessments have been gaining importance in the assessment of acute PE. Current limitations to the use of echocardiography for risk assessment in acute PE are the lack of normative values for RV parameters, the absence of standardization of measurements across different ultrasound platforms, and the heterogeneity of the performance of echocardiographic examinations and reports across centers.

Keywords

pulmonary embolism - echocardiography - right ventricle
 

  • References

  • 1 Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003; 163 (14) 1711-1717
    CrossrefPubMedSearch in Google Scholar
  • 2 Konstantinides SV, Torbicki A, Agnelli G , et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
    CrossrefPubMedSearch in Google Scholar
  • 3 Torbicki A, Perrier A, Konstantinides S , et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29 (18) 2276-2315
    CrossrefPubMedSearch in Google Scholar
  • 4 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162): 1386-1389
    CrossrefPubMedSearch in Google Scholar
  • 5 Guyatt GH, Norris SL, Schulman S , et al. Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): 53s-70s
    CrossrefPubMedSearch in Google Scholar
  • 6 Rudski LG, Lai WW, Afilalo J , et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23 (7) 685-713 , quiz 786–788
    CrossrefPubMedSearch in Google Scholar
  • 7 Lang RM, Bierig M, Devereux RB , et al; Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18 (12) 1440-1463
    CrossrefPubMedSearch in Google Scholar
  • 8 McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996; 78 (4) 469-473
    CrossrefPubMedSearch in Google Scholar
  • 9 Vitarelli A, Barillà F, Capotosto L , et al. Right ventricular function in acute pulmonary embolism: a combined assessment by three-dimensional and speckle-tracking echocardiography. J Am Soc Echocardiogr 2014; 27 (3) 329-338
    CrossrefPubMedSearch in Google Scholar
  • 10 Park JH, Kim JH, Lee JH, Choi SW, Jeong JO, Seong IW. Evaluation of right ventricular systolic function by the analysis of tricuspid annular motion in patients with acute pulmonary embolism. J Cardiovasc Ultrasound 2012; 20 (4) 181-188
    CrossrefPubMedSearch in Google Scholar
  • 11 Özsu S, Kırış A, Bülbül Y , et al. Relationship between cardiac troponin-T and right ventricular Tei index in patients with hemodynamically stable pulmonary embolism: an observational study. Anadolu Kardiyol Derg 2012; 12 (8) 659-665
    PubMedSearch in Google Scholar
  • 12 Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest 1997; 111 (1) 209-217
    CrossrefPubMedSearch in Google Scholar
  • 13 Kline JA, Nordenholz KE, Courtney DM , et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014; 12 (4) 459-468
    CrossrefPubMedSearch in Google Scholar
  • 14 Poterucha TJ, Bergmark B, Aranki S, Kaneko T, Piazza G. Surgical pulmonary embolectomy. Circulation 2015; 132 (12) 1146-1151
    CrossrefPubMedSearch in Google Scholar
  • 15 Fischer JI, Huis in 't Veld MA, 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
    CrossrefPubMedSearch in Google Scholar
  • 16 Schaefer A, Treede H, Reichenspurner H, Conradi L. Large biatrial thrombembolus caught in transit across a patent foramen ovale. Thorac Cardiovasc Surg Rep 2015; 4 (1) 44-45
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Bommer W, Weinert L, Neumann A, Neef J, Mason DT, DeMaria A. Determination of right atrial and right ventricular size by two-dimensional echocardiography. Circulation 1979; 60 (1) 91-100
    CrossrefPubMedSearch in Google Scholar
  • 18 Lang RM, Badano LP, Mor-Avi V , et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28 (1) 1-39 .e14
    CrossrefPubMedSearch in Google Scholar
  • 19 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 (1) 89-95
    CrossrefPubMedSearch in Google Scholar
  • 20 Taylor RA, Moore CL. Accuracy of emergency physician-performed limited echocardiography for right ventricular strain. Am J Emerg Med 2014; 32 (4) 371-374
    CrossrefPubMedSearch in Google Scholar
  • 21 Lai WW, Gauvreau K, Rivera ES, Saleeb S, Powell AJ, Geva T. Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography. Int J Cardiovasc Imaging 2008; 24 (7) 691-698
    CrossrefPubMedSearch in Google Scholar
  • 22 Mediratta A, Addetia K, Medvedofsky D, Gomberg-Maitland M, Mor-Avi V, Lang RM. Echocardiographic diagnosis of acute pulmonary embolism in patients with McConnell's sign. Echocardiography 2016; 33 (5) 696-702
    CrossrefPubMedSearch in Google Scholar
  • 23 López-Candales A, Edelman K, Candales MD. Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited. Echocardiography 2010; 27 (6) 614-620
    CrossrefPubMedSearch in Google Scholar
  • 24 Rajagopal S, Forsha DE, Risum N , et al. Comprehensive assessment of right ventricular function in patients with pulmonary hypertension with global longitudinal peak systolic strain derived from multiple right ventricular views. J Am Soc Echocardiogr 2014; 27 (6) 657-665 .e3
    CrossrefPubMedSearch in Google Scholar
  • 25 Tuzovic M, Adigopula S, Amsallem M , et al. Regional right ventricular dysfunction in acute pulmonary embolism: relationship with clot burden and biomarker profile. Int J Cardiovasc Imaging 2016; 32 (3) 389-398
    CrossrefPubMedSearch in Google Scholar
  • 26 Platz E, Hassanein AH, Shah A, Goldhaber SZ, Solomon SD. Regional right ventricular strain pattern in patients with acute pulmonary embolism. Echocardiography 2012; 29 (4) 464-470
    CrossrefPubMedSearch in Google Scholar
  • 27 Mansencal N, Joseph T, Vieillard-Baron A , et al. Comparison of different echocardiographic indexes secondary to right ventricular obstruction in acute pulmonary embolism. Am J Cardiol 2003; 92 (1) 116-119
    CrossrefPubMedSearch in Google Scholar
  • 28 Frémont 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 (2) 358-362
    CrossrefPubMedSearch in Google Scholar
  • 29 Khemasuwan D, Yingchoncharoen T, Tunsupon P , et al. Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J Am Soc Echocardiogr 2015; 28 (3) 355-362
    CrossrefPubMedSearch in Google Scholar
  • 30 Chow V, Ng AC, Chung T, Thomas L, Kritharides L. Right atrial to left atrial area ratio on early echocardiography predicts long-term survival after acute pulmonary embolism. Cardiovasc Ultrasound 2013; 11: 17
    CrossrefPubMedSearch in Google Scholar
  • 31 Zanobetti M, Converti C, Conti A , et al. Prognostic value of emergency physician performed echocardiography in patients with acute pulmonary thromboembolism. West J Emerg Med 2013; 14 (5) 509-517
    CrossrefPubMedSearch in Google Scholar
  • 32 Ryan T, Petrovic O, Dillon JC, Feigenbaum H, Conley MJ, Armstrong WF. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985; 5 (4) 918-927
    CrossrefPubMedSearch in Google Scholar
  • 33 López-Candales A, Dohi K, Rajagopalan N , et al. Right ventricular dyssynchrony in patients with pulmonary hypertension is associated with disease severity and functional class. Cardiovasc Ultrasound 2005; 3: 23
    CrossrefPubMedSearch in Google Scholar
  • 34 Cetiner MA, Sayın MR, Yıldırım N, Karabağ T, Aydın M. The association of eccentricity indexes with cardiac biomarkers in normotensive acute pulmonary embolism patients: an observational study. Anadolu Kardiyol Derg 2013; 13 (2) 108-114
    PubMedSearch in Google Scholar
  • 35 Jiménez D, Kopecna D, Tapson V , et al; On Behalf Of The Protect Investigators. Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med 2014; 189 (6) 718-726
    CrossrefPubMedSearch in Google Scholar
  • 36 Kaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J 1984; 107 (3) 526-531
    CrossrefPubMedSearch in Google Scholar
  • 37 Schmid E, Hilberath JN, Blumenstock G , et al. Tricuspid annular plane systolic excursion (TAPSE) predicts poor outcome in patients undergoing acute pulmonary embolectomy. Heart Lung Vessel 2015; 7 (2) 151-158
    PubMedSearch in Google Scholar
  • 38 Imada T, Kamibayashi T, Ota C , et al. Intraoperative right ventricular fractional area change is a good indicator of right ventricular contractility: a retrospective comparison using two- and three-dimensional echocardiography. J Cardiothorac Vasc Anesth 2015; 29 (4) 831-835
    CrossrefPubMedSearch in Google Scholar
  • 39 Vizzardi E, Bonadei I, Sciatti E , et al. Quantitative analysis of right ventricular (RV) function with echocardiography in chronic heart failure with no or mild RV dysfunction: comparison with cardiac magnetic resonance imaging. J Ultrasound Med 2015; 34 (2) 247-255
    CrossrefPubMedSearch in Google Scholar
  • 40 Park JH, Park YS, Park SJ , et al. Midventricular peak systolic strain and Tei index of the right ventricle correlated with decreased right ventricular systolic function in patients with acute pulmonary thromboembolism. Int J Cardiol 2008; 125 (3) 319-324
    CrossrefPubMedSearch in Google Scholar
  • 41 Lindqvist P, Söderberg S, Gonzalez MC, Tossavainen E, Henein MY. Echocardiography based estimation of pulmonary vascular resistance in patients with pulmonary hypertension: a simultaneous Doppler echocardiography and cardiac catheterization study. Eur J Echocardiogr 2011; 12 (12) 961-966
    CrossrefPubMedSearch in Google Scholar
  • 42 Forsha D, Risum N, Rajagopal S , et al. The influence of angle of insonation and target depth on speckle-tracking strain. J Am Soc Echocardiogr 2015; 28 (5) 580-586
    CrossrefPubMedSearch in Google Scholar
  • 43 Forsha DE, Risum N, Smith PB , et al. A novel comprehensive RV strain analysis: echocardiographic approach to define a normal adult population. American Heart Association Scientific Sessions 2012; Los Angeles, CA. Abstract 9974
    PubMed
  • 44 Voigt JU, Pedrizzetti G, Lysyansky P , et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 2015; 16 (1) 1-11
    CrossrefPubMedSearch in Google Scholar
  • 45 Sachdev A, Villarraga HR, Frantz RP , et al. Right ventricular strain for prediction of survival in patients with pulmonary arterial hypertension. Chest 2011; 139 (6) 1299-1309
    CrossrefPubMedSearch in Google Scholar
  • 46 Giusca S, Jurcut R, Coman IM , et al. Right ventricular function predicts clinical response to specific vasodilator therapy in patients with pulmonary hypertension. Echocardiography 2013; 30 (1) 17-26
    CrossrefPubMedSearch in Google Scholar
  • 47 Haeck ML, Scherptong RW, Marsan NA , et al. Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension. Circ Cardiovasc Imaging 2012; 5 (5) 628-636
    CrossrefPubMedSearch in Google Scholar
  • 48 Motoji Y, Tanaka H, Fukuda Y , et al. Efficacy of right ventricular free-wall longitudinal speckle-tracking strain for predicting long-term outcome in patients with pulmonary hypertension. Circ J 2013; 77 (3) 756-763
    CrossrefPubMedSearch in Google Scholar
  • 49 Takamura T, Dohi K, Onishi K , et al. Reversible left ventricular regional non-uniformity quantified by speckle-tracking displacement and strain imaging in patients with acute pulmonary embolism. J Am Soc Echocardiogr 2011; 24 (7) 792-802
    CrossrefPubMedSearch in Google Scholar
  • 50 Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of, Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2016; 17 (4) 412
    CrossrefPubMedSearch in Google Scholar
  • 51 Kopecna D, Briongos S, Castillo H , et al; PROTECT investigators. Interobserver reliability of echocardiography for prognostication of normotensive patients with pulmonary embolism. Cardiovasc Ultrasound 2014; 12: 29
    CrossrefPubMedSearch in Google Scholar
  • 52 Meyer G, Vicaut E, Danays T , et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
    CrossrefPubMedSearch in Google Scholar
  • 53 Chatterjee S, Chakraborty A, Weinberg I , et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311 (23) 2414-2421
    CrossrefPubMedSearch in Google Scholar
  • 54 Piazza G, Hohlfelder B, Jaff MR , et al; SEATTLE II Investigators. A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: The SEATTLE II Study. JACC Cardiovasc Interv 2015; 8 (10) 1382-1392
    CrossrefPubMedSearch in Google Scholar
  • 55 Kuo WT, Banerjee A, Kim PS , et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest 2015; 148 (3) 667-673
    CrossrefPubMedSearch in Google Scholar