ΠΝΔΤΜΟΝΙΚΗ ΔΜΒΟΛΗ Ο ΡΟΛΟ ΣΗ ΓΔΞΙΑ ΚΟΙΛΙΑ Γ. Καρατασάκης ΔΚΔ 02/11/12
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 600.000 France 100.000 England and Wales 65.000 Italy60.000 Dalen JE et al. Prog Cardiovasc Dis 1975 ESC Guidelines, Eur Heart J 2000
No indication for echo in low risk PE
RV
Diagnostic modalities for assessing RV function Angiography RNA Echocardiography TDI MRI RNA widely used, angiography and MRI uncommon
Sa
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%
TDI and RV Acceleration during isovolumic contraction (IVA) is ralated to systolic RVFn independent from loading conditions. Vogel M. et al.,circulation 2002;105:1693-9 IVA is not clinically tested. Weyman A.E.,JACC 2004;43:140-148 Recording of IVA is difficult (multidirectional). Lindqvist P.et al, Eur J.Echocardiogr 2005;6:264-270
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, 82:329-334 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
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
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
60/60 SIGN Pulmonary ejection acceleration time in RVOT of 60ms in the presence of tricuspid insufficiency pressure gradient 60mmHg AcT 60ms TRPG 60mmHg
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
283 pts VQ
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
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
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
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
DIAGNOSIS OF CENTRAL MASSIVE PE BY TEE Popovic AD, Neskovic AN, et al. Cardiology 1992
Highly selected pts
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
The importance of RVFn in PE. One year F/U
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
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
PFO IS IMPORTANT PREDICTOR OF ADVERSE OURCOME IN PTS WITH MAJOR PE Konstantinides S, et al. Circ 1998
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
283 pts VQ
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)
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;22:340-348 Sv affected by RV afterload and HR. Inversely related to PAP. Vogel M. et al,circulation 2002;105:1693-9
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
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
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
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
RV dilation/hypokinesis LV geometrical changes
RV dilation/hypokinesis Flattened IVS
Acute pulmonary hypertension TV systolic gradient typically 60mmHg (TR jet velocity, modified Bernoulli equation)
Characteristic alteration of pulmonary ejection flow pattern ACT <60ms Midsystolic deceleration ( notching ) Courtesy of Pruszczyk P
Dilated IVC, non-colapsable in inspirium
WHAT IS THE REAL DIAGNOSTIC VALUE OF ECHO SIGNS SUGGESTING PULMONARY EMBOLISM?
IMPROVEMENT OF DIAGNOSTIC ACCURACY OF TEE BY COLOR DOPPLER IN CASES WITH INCOMPLETE OBSTRUCTION Neskovic AN, Popovic AD et al. Echocardiography 1996
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.
3-MONTH SURVIVAL ACCORDING TO THE PRESENCE OR ABSENCE OF RIGHT HEART THROMBI ON BASELINE ECHO Torbicki A, et al (ICOPER), JACC 2003
DIFFERENTIAL DIAGNOSIS OF PE Secondary pulmoary hypertension RV infarction Atrial septal defect Pulmonary stenosis Primary pulmonary hypertension Aortic dissection Tamponade ARDS ARVD
Day 1, before Th Day 3, after thrombolysis
Day 1, before Th Day 3, after thrombolysis
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
INCIDENCE OF PE Annual estimated rate USA 600.000 France 100.000 England and Wales 65.000 Italy 60.000 Dalen JE et al. Prog Cardiovasc Dis 1975 ESC Guidelines, Eur Heart J 2000
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
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
The importance of RVFn in PE
RV DYSFUNCTION Dilation Hypokinesis McConnell s sign
REGIONAL RV DYSFUNCTION IN ACUTE PE McConnell s sign distinct echocardiographic pattern of RV dysfunction McConnell MV, et al, AJC 1996
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, 95:1039-1042 Reduced Ev (< 8.5cm/sec) has been used as a prognosticator in children with DCM. Mc Mahon C.J. et al, Heart 2004, 90:908-915 Reduced Sv and Strain of the RV are bad prognostic indices in pulmonary hypertension. Lopez-Candales A Am J Cardiol 2005,96:602-606
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
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
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!
IDEAL ROLE OF ECHO IN SUSPECTED PE Diagnosis Identification of high-risk pts Monitoring the effect of therapy Differential diagnosis
Systolic annular velocity (Sa) was related to RNA RVEF. Sa<11.5cm/sec: 90% sensitivity, 85% specificity for RVEF<45%
Assessing RV function Crescent shaped Complex geometry Interdependence with LV Heavily trabeculated Thin walls Loading conditions
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.
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
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
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
PREVALENCE OF McCONNELL SIGN IN PTS WITH ACUTE PE AND RV INFARCTION
Acute Right Ventricular HF Acute RV MI Massive acute PE Severe acute TR LV originated acute decompensation Acute Myocarditis
MAJOR STUDIES EVALUATING DIAGNOSTIC VALUE OF ECHO SIGNS SUGGESTING PULMONARY EMBOLISM
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;6:264-270