ΠΝΔΤΜΟΝΙΚΗ ΔΜΒΟΛΗ Ο ΡΟΛΟ ΣΗ ΓΔΞΙΑ ΚΟΙΛΙΑ

Transcription

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2 ΠΝΔΤΜΟΝΙΚΗ ΔΜΒΟΛΗ Ο ΡΟΛΟ ΣΗ ΓΔΞΙΑ ΚΟΙΛΙΑ Γ. Καρατασάκης ΔΚΔ 02/11/12

3 FACTS ON PE Related to DVT High morbidity Mortality is (still) high Low detection rate before death Frequent overdiagnosis and overtreatment Aggressive therapy required INCIDENCE Annual estimated rate USA France England and Wales Italy Dalen JE et al. Prog Cardiovasc Dis 1975 ESC Guidelines, Eur Heart J 2000

4 No indication for echo in low risk PE

5 RV

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7 Diagnostic modalities for assessing RV function Angiography RNA Echocardiography TDI MRI RNA widely used, angiography and MRI uncommon

8 Sa

9 Correlation of tricuspid annular velocity with RNA RVEF. HF pts (44) and normal controls (30) Normals: 15.5±2.6 cm/sec Pts (RVEF<30%): 10.3±2.6 cm/sec Systolic annular velocity (Sa) was related to RNA RVEF. Sa<11.5cm/sec: 90% sensitivity, 85% specificity for RVEF<45%

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11 TDI and RV Acceleration during isovolumic contraction (IVA) is ralated to systolic RVFn independent from loading conditions. Vogel M. et al.,circulation 2002;105: IVA is not clinically tested. Weyman A.E.,JACC 2004;43: Recording of IVA is difficult (multidirectional). Lindqvist P.et al, Eur J.Echocardiogr 2005;6:

12 Prognostic indices in RV Tricuspid annular systolic excursion TAPSE < 12.5 mm is an independent prognostic index in severe heart failure Karatasakis G. et al, Am J Cardiol 1998, 82: Sv 10.8 cm/sec,ev 8.9 cm/sec IVA 2,5m/sec2 and ΤΕΙ 1,2 have important prognostic meaning. Meluzin J. et al, JASE 2005, 18:5

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15 PATHOPHYSIOLOGY OF ACUTE PE Doppler and 2D Echo Acute obstruction >25% of pulmonary vascular bad Acute pulmonary hypertension Acute RV pressure overload RV hypokinesis, dilation, dysfunction Tricuspid regurgitation Displacement of the septum Towards LV cavity Reduced LV preload LV dysfunction Low CO, shock

16 ECHO SIGNS OF PE RV dilatation/hypokinesis and subsequent TR RA dilation?? Dilation (>20mm), non-collapsing (inspr) IVC Flattened interventricular septum Decreased LV size Increased RV/LV end-diastolic diameter ratio TR jet >2.5m/s (mild-moderate PA hypertension) RVOT mid-systolic notching pattern (AccT <80 ms, with mid-systolic deceler) Direct thrombus visualization in the rigt heart or PA

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18 60/60 SIGN Pulmonary ejection acceleration time in RVOT of 60ms in the presence of tricuspid insufficiency pressure gradient 60mmHg AcT 60ms TRPG 60mmHg

19 Regional rv dysfunction in acute PE McConell s sign RV free wall hypokinesis with normal wall motion of the RV apex 14 pts with PE 9 pts with PPH 18 normal controls McConnell MV, et al, AJC 1996

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21 283 pts VQ

22 DIAGNOSTIC VALUE OF ECHO IN PE Echo Dg of PE, if any 2 of 3: -RV EDD >27mm -RV hypokinesis -TR velocity >2.7m/s At least 2/3 criteria were present in: -24/43 pts with angio-proven PE -7/67 pts without PE Sn 56% Sp 90% Miniati M, et al, Am J Med 2001

23 DIAGNOSTIC VALUE OF ECHO IN PE TTE has limited diagnostic value: it fails to identify ~50% of pts with angio-proven PE in a prospective study of unselected pts Should not be used for PE screening Miniati M, et al, Am J Med 2001

24 ACUTE PULMONARY HYPERTENSION Vs. chronic: Dilated, hypokinetic RV (McDonnell?) Absence of RV hypertrophy Absence of significant left heart pathology TR, with flow velocities indicating mild to moderate elevation of PAP

25 TEE IN DIAGNOSIS OF PE Direct visualization of thrombus in proximal parts of pulmonary arteries and right heart Good sensitivity in selected pts High specificity If intraluminal mass with distinct borders, different in echodensity from the vascular wall is considered as thrombus Experience/learning curve (left PA?) Special care to avoid overdiagnosis of acute PE TEE result often serves as justification of aggressive TH

26 DIAGNOSIS OF CENTRAL MASSIVE PE BY TEE Popovic AD, Neskovic AN, et al. Cardiology 1992

27 Highly selected pts

28 IMPACT OF RV DYSFUNCTION ON SURVIVAL* IN PTS WITH ACUTE PE AND PRESERVED SYSTOLIC ARTERIAL PRESSURE 1035 ICOPER pts with PE SBP 90mmHg at presentation Baseline echo for RV hypokinesis

29 The importance of RVFn in PE. One year F/U

30 Survival Ribeiro A, et al. AHJ 1997 RV DYSFUNCTION AS A MARKER OF WORSE OUTCOME IN PTS WITH PE 126 pts with PE RV function assessed by WMA analysis Days

31 PROGNOSTIC SIGNIFICANCE OF RV AFTERLOAD STRESS IN PTS WITH SUSPECTED PE 317 pts with clinically suspected PE Echo for the presence of RV afterload stress Kasper W, et al. Heart 1997

32 PFO IS IMPORTANT PREDICTOR OF ADVERSE OURCOME IN PTS WITH MAJOR PE Konstantinides S, et al. Circ 1998

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38 ECHO IN MONITORING EFFECTS OF THERAPY FOR PE Reversal of RV dysfunction Normalization of RV ejection flow Reduction of PA systolic pressure Disappearance of thrombi

39 283 pts VQ

40 ECHO IN PE Should not be used as a screening test for PE due to low sensitivity in unselected pts May be useful in identifying pts with poor prognosis (RV dysfunction, PFO, right heart thrombus) Monitoring of therapy by echo is useful in pts with positive echo signs at baseline TEE allows bedside direct confirmation of PE in selected pts with RV strain (in ~80% of cases)

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42 RV Fn and TDI Systolic annular velocity is an index of longitudinal RV Fn (Sv<11,5 cm/sec predict RVEF<45%, sens :90%, specific: 85%). Meluzin J. et al, Eur Heart J 2001;22: Sv affected by RV afterload and HR. Inversely related to PAP. Vogel M. et al,circulation 2002;105:1693-9

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47 IMPORTANT FACTS ON PE Prevalence of PE at autopsy is 12-15% Unchanged during last 30 years Numerous cases unrecognized/untreated Mortality if untreated is ~30% could be reduced to 2-8% ESC Guidelines, Eur Heart J 2000 Stein PD et al, CHEST 1995

48 MORTALITY ASSOCIATED TO PULMONARY EMBOLISM CAN BE REDUCED! Majority of preventable deaths due to PE (range 27-68%) can be ascribed to missed Df rather than existing therapies failure Fedullo PF et al, NEJM 2003 Goldhaber SZ et al, Lancet 1999

49 PATHOPHYSIOLOGY OF ACUTE PE Acute obstruction >25% of pulmonary vascular bad Acute pulmonary hypertension Acute RV pressure overload RV hypokinesis, dilation, dysfunction Tricuspid regurgitation Displacement of the septum Towards LV cavity Reduce LV preload LV dysfunction Low CO, shock

50 Direct sign of PE, thrombus in RVOT Only in 4% of pts in ICOPER* (International Cooperative Pulmonary Embolism Registry) *Goldhaber SZ et al, Lancet 1999

51 RV dilation/hypokinesis LV geometrical changes

52 RV dilation/hypokinesis Flattened IVS

53 Acute pulmonary hypertension TV systolic gradient typically 60mmHg (TR jet velocity, modified Bernoulli equation)

54 Characteristic alteration of pulmonary ejection flow pattern ACT <60ms Midsystolic deceleration ( notching ) Courtesy of Pruszczyk P

55 Dilated IVC, non-colapsable in inspirium

56 WHAT IS THE REAL DIAGNOSTIC VALUE OF ECHO SIGNS SUGGESTING PULMONARY EMBOLISM?

57 IMPROVEMENT OF DIAGNOSTIC ACCURACY OF TEE BY COLOR DOPPLER IN CASES WITH INCOMPLETE OBSTRUCTION Neskovic AN, Popovic AD et al. Echocardiography 1996

58 TEE IN DIAGNOSIS OF PE TEE can be used for bedside confirmation of significant PE in 80% of cases. However, due to topographic limitations it can not rule out PE. Bedside TEE: 1 st choice Dg test in selected pts with RV dysfunction, shock, or during CPR.

59 3-MONTH SURVIVAL ACCORDING TO THE PRESENCE OR ABSENCE OF RIGHT HEART THROMBI ON BASELINE ECHO Torbicki A, et al (ICOPER), JACC 2003

60 DIFFERENTIAL DIAGNOSIS OF PE Secondary pulmoary hypertension RV infarction Atrial septal defect Pulmonary stenosis Primary pulmonary hypertension Aortic dissection Tamponade ARDS ARVD

61 Day 1, before Th Day 3, after thrombolysis

62 Day 1, before Th Day 3, after thrombolysis

63 In 1996, by means of quantitative and qualitative analyses, McConnell et al. described in pulmonary embolism a distinct echocardiographic pattern of RV dysfunction, characterized by a severe hypokinesia of RV mid-free wall, with a normal contraction of the apical segment9 (Fig. 1a,b). In comparison with several conditions involving the RV, the finding showed a 77% sensitivity and a 94% specificity, with a positive and negative predictive values of 71 and 96%, respectively

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67 INCIDENCE OF PE Annual estimated rate USA France England and Wales Italy Dalen JE et al. Prog Cardiovasc Dis 1975 ESC Guidelines, Eur Heart J 2000

68 ACUTE PULMONARY HYPERTENSION Vs. chronic: Dilated, hypokinetic RV (McDonnell?) Absence of RV hypertrophy Absence of significant left heart pathology TR, with flow velocities indicating mild to moderate elevation of PAP

69 SURVIVAL OF PTS WITH PULMONARY EMBOLISM Medicare pts with DVT and PE Enrolles matched for age, sex and race Kniffin WD Jr et al, Arch Intern Med 1994

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73 The importance of RVFn in PE

74 RV DYSFUNCTION Dilation Hypokinesis McConnell s sign

75 REGIONAL RV DYSFUNCTION IN ACUTE PE McConnell s sign distinct echocardiographic pattern of RV dysfunction McConnell MV, et al, AJC 1996

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79 TDI RV indices and PROGNOSIS Reduced Sv (7.7 ± 2.5 cm/sec) and reduced early diastolic velocity Ev (6.3 ± 2.3 cm/sec) predict increased mortality in pts with RV infarction Dokainish H. et al, Am J Cardiol 2005, 95: Reduced Ev (< 8.5cm/sec) has been used as a prognosticator in children with DCM. Mc Mahon C.J. et al, Heart 2004, 90: Reduced Sv and Strain of the RV are bad prognostic indices in pulmonary hypertension. Lopez-Candales A Am J Cardiol 2005,96:

80 ECHO SIGNS OF RV DYSFUNCTION almost identical to previous slide RV/LV EDD >1 RV EDD >30 mm (RV dilation) RV hypokinesis Paradoxical RV septal motion McConnell s sign

81 IMPACT OF RV DYSFUNCTION ON SURVIVAL* IN PTS WITH ACUTE PE AND PRESERVED SYSTOLIC ARTERIAL PRESSURE 1035 ICOPER pts with PE SBP 90mmHg at presentation Baseline echo for RV hypokinesis

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83 DIAGNOSTIC EVALUATION IN SUSPECTED PE D-dimer, BNP, troponin Chest x-ray, ECG V/P lung scan Spiral-CT Pulmonary angiography Angioscopy MSCT Duplex ultrasonography Echocardiography (TTE, TEE) No single noninvasive diagnostic test is sensitive or specific enough! Sequential diagnostic approach is necessary!

84 IDEAL ROLE OF ECHO IN SUSPECTED PE Diagnosis Identification of high-risk pts Monitoring the effect of therapy Differential diagnosis

85 Systolic annular velocity (Sa) was related to RNA RVEF. Sa<11.5cm/sec: 90% sensitivity, 85% specificity for RVEF<45%

86 Assessing RV function Crescent shaped Complex geometry Interdependence with LV Heavily trabeculated Thin walls Loading conditions

87 TDI IN RV Permits evaluation of longitudinal function Real time estimation of systolic and diastolic velocity-strain -function Precise event timing ΤDI indices relatively independent from loading conditions and geometry when compared to 2-D indices Can be measured in a variety of myocardial locations (beyond the annulus) Simplicity, feasibility, reproducibility.

88 RATIONALE FOR ECHO IN PE Rarely, direct visualization of thrombus in the right heart and/or PA is possible Pathophysiological responses to increased pulmonary pressure can be easily detected by echo (indirect signs) Noninvasive, available, portable

89 Mc Connell sign In 1996, by means of quantitative and qualitative analyses, McConnell et al. described in pulmonary embolism a distinct echocardiographic pattern of RV dysfunction, characterized by a severe hypokinesia of RV mid-free wall, with a normal contraction of the apical segment9 (Fig. 1a,b). In comparison with several conditions involving the RV, the finding showed a 77% sensitivity and a 94% specificity, with a positive and negative predictive values of 71 and 96%, respectively

90 DIAGNOSTIC VALUE OF ECHO IN PE Possible sources of confusion: There are only few prospective studies Major dirrerences in: Patient s selection Severity of PE Previous cardiorespiratory disease Diagnostic echo criteria Enrolled pts were not a representative sample of the severity spectrum of the disease Majority had massive and submassive PE

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94 PREVALENCE OF McCONNELL SIGN IN PTS WITH ACUTE PE AND RV INFARCTION

95 Acute Right Ventricular HF Acute RV MI Massive acute PE Severe acute TR LV originated acute decompensation Acute Myocarditis

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97 MAJOR STUDIES EVALUATING DIAGNOSTIC VALUE OF ECHO SIGNS SUGGESTING PULMONARY EMBOLISM

98 TDI and RVfn Systolic annular velocity during Isovolumic contraction (IVCv), is a reliable index of systolic RVFn IVCv<6 cm/sec is related to elevated RV filling pressure Lindqvist P. et al, Eur J Echocardiogr. 2005;6:

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