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Echocardiography in the Management of Pulmonary Embolism

Samuel Z. Goldhaber, MD
[+] Article and Author Information

From Brigham and Women's Hospital, Boston, Massachusetts.


Acknowledgments: The author thanks the following echocardiographers, who provided useful critique with rapid turnaround time: Michèle A. Hamilton, MD (University of California, Los Angeles, Los Angeles, California); Richard T. Lee, MD (Brigham and Women's Hospital, Boston, Massachusetts); Sharon C. Reimold, MD (University of Texas Southwestern, Dallas, Texas); and Keith Comess, MD (Dartmouth Medical School, Hanover, New Hampshire).

Requests for Single Reprints: Samuel Z. Goldhaber, MD, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail, sgoldhaber@partners.org.


Ann Intern Med. 2002;136(9):691-700. doi:10.7326/0003-4819-136-9-200205070-00012
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Echocardiography is not recommended as a routine imaging test to diagnose suspected pulmonary embolism. However, it is useful for identifying patients with pulmonary embolism who may have a poor prognosis. It can be used for rapid and accurate risk assessment. Moderate or severe right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and free-floating right-heart thrombus are echocardiographic markers that identify patients at risk for death or recurrent thromboembolism. Such patients warrant consideration for thrombolysis or embolectomy. Serial imaging of right ventricular function can help physicians monitor the effect of treatment and judge whether the selected management strategy is successful. Further research will clarify and define more precisely the utility and limitations of echocardiography in the management of pulmonary embolism.

Figures

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Figure 1.
Typical findings on transthoracic echocardiography in patients with massive pulmonary embolism.RVLVleftrightarrowsPE(4)

In patients with pulmonary embolism, the transthoracic echocardiogram rarely shows thrombus; instead, findings suggestive of pulmonary embolism may be observed. Shown here are parasternal short-axis views of the right ventricle ( ) and left ventricle ( ) in diastole ( ) and systole ( ) in a patient with angiographically proved pulmonary embolism. There is diastolic and systolic bowing of the interventricular septum ( ) into the left ventricle, a finding compatible with the presence of right ventricular volume overload and pressure overload, respectively. The left ventricle has assumed a classic D-shaped configuration, indicating impaired left ventricular relaxation. The right ventricle is appreciably dilated and markedly hypokinetic, with little change in the apparent right ventricular area from diastole to systole. There is a small pericardial effusion ( ). Reprinted with permission from Come .

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Figure 2.
Right main pulmonary artery embolism visualized on transthoracic echocardiography.RPA

This aortic arch view shows the relationship between the aorta and the right main pulmonary artery. Thrombus is seen in the right pulmonary artery ( ). AO = aorta; AO arch = aortic arch; DESC AO = descending aorta; hp = Hewlett Packard. Courtesy of José Rivero, with permission.

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Figure 3.
Apical four-chamber view from a transthoracic two-dimensional echocardiogram.(11)

Qualitative wall-motion scores were assigned at four locations of the right ventricular free wall (shaded areas). The excursion of the right ventricular free wall was measured from end-diastole to end-systole, and a centerline was defined midway between the diastolic and systolic curves. Chord lengths were then defined perpendicular to the centerline extending from the diastolic to the systolic curve. Forty measurements were obtained from the right ventricular base to the right ventricular apex. LV = left ventricle; RV = right ventricle. Reprinted from McConnell et al. ; Am J Cardiol, pp 469-473, copyright 1996, with permission of Excerpta Medica.

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Figure 4.
Segmental right ventricular free-wall excursion (mean ±SE) by centerline analysis as a function of right ventricular free-wall segment.PP(11)

The 40 right ventricular free-wall segments were arbitrarily numbered from 1 at the base to 40 at the apex. The centerline excursion was then plotted at each of these 40 intervals. This process generated a curve for normal right ventricular function in which the centerline excursion remained fairly constant at 7 to 8 mm. Centerline excursion in patients with acute pulmonary embolism was near normal at the apex (shaded area) but abnormal at the mid-free wall and base ( < 0.02 compared with normal). Centerline excursion in patients with primary pulmonary hypertension was reduced compared with that in normal persons in all segments ( < 0.03). Reprinted from McConnell et al. ; Am J Cardiol, pp 469-473, copyright 1996, with permission of Excerpta Medica.

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Figure 5.
Transesophageal short-axis view at the level of the pulmonary artery bifurcation, demonstrating thrombus in the right pulmonary artery (RPA).LPAAo(14)

Also shown are the left pulmonary artery ( ) and aorta ( ). hp = Hewlett Packard; MPA = main pulmonary artery. Reprinted with permission from Comess et al. ; Am J Med, pp 351-356, copyright 2000, with permission of Excerpta Medica. The electronic original of the figure was kindly provided by Keith A. Comess, MD.

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Figure 6.
Right ventricular wall-motion excursion and range for normal persons, patients with acute pulmonary embolism, and patients with pulmonary embolism on follow-up after thrombolysis.(24)

Wall-motion excursion was significantly different from normal in chord numbers 9 to 37 in patients with acute pulmonary embolism. Wall-motion excursion did not significantly differ from normal at any location on follow-up echocardiography. The bars represent SEs. Reprinted with permission from Nass et al. ; Am J Cardiol, pp 804-806, copyright 1999, with permission of Excerpta Medica.

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