AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.
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The echocardiographic findings in this patient are:
A mass in the pulmonary artery
Right Ventricular Dilation
Right Ventricular Hypokinesis
Right Atrial Enlargement
Leftward Septal Motion
The diagnosis is an acute, massive pulmonary embolus.
Other echocardiographic findings that could be present are:
Pulmonary Artery Enlargement
Hepatic Vein Doppler Systolic Reversal
Small Left Atrium
Small Left Ventricle
Other diseases that may simulate this patient's symptoms are:
Acute Myocardial Ischemia
Acute Myocardial Infarction
The tests that could be ordered are:
Computed Tomographic Angiography (CTA)
The pulmonary angiogram has been the old gold standard. A pulmonary angiogram is time consuming, carries a small risk (0.1% mortality), exposes the patient to the risk of dye, and may miss small, subsegmental emboli.
A CTA is the new gold standard. A CTA is widely available, fast, and can show the emboli in the main pulmonary artery or in the segmental arteries. A CTA may miss the subsegmental emboli. A CTA can be used to diagnosis right ventricular dysfunction.
A CTA can also rule out other causes of the patient's symptoms such as a pneumothorax or pericardial effusion.
An MRI is not a widely available as a CTA but has good sensitivity and specificity for a pulmonary embolus. Again, MRI may miss subsegmental emboli. MRIs are usually resevered for patients who have a contraindication o a CTA (dye, radiation).
A V/Q scan is time consuming and may be less reliable in patients with significant ung disease.
An echocardiogram is useful in finding secondary findings of the pulmonary embolus if the emboli are large enough. An echocardiography can only find clot in the large pulmonary arteries. An echocardiogram can rule out other causes of a patient's symptoms such as atrial myxoma, mitral stenosis, aortic stenosis, myocardial infarction/ischemia. An echocardiography may only find the secondary signs of a pulmonary embolus. The apexof the right ventricle may be spared while the free wall of the right ventricle is hypokinetic. In chronic pulmonary hypertension the free wall AND the apex are hypokinetic. RV dysfunction is prognostic of a higher mortality rate and is an indication of agressive therapy.
While a pulmonary angiogram has high sensitivity and specificity, a CTA approaches 90% sensitivity and specificity. The current recommendations are to perform an echocardiography screening exam and if no diagnosis can be made, hen a CTA can be
performed. This protocol decreases the incidence of exposure to radiation and dye for a patient.
Therapy options for a pulmonary embolus are:
Anticoagulation is the most common therapy. Unfractionated heparing increases the risk of HIT, so low molecular weight heparin or Fondoprax is used.
Thrombolysis is reserved for patients who are unstable and do not have a contraindication to thrombolysis. Interestingly, thrombolytic therapy, while obviously helpful in the unstable patient, did not improve the outcome of patients compared to anticoagulation alone. An IVC filter may improve the outcome if used along with thrombolytic therapy.
Thrombectomy, either by surgical or catheter methods is reserved for patients who have a contraindication to thrombolysis and are unstable or where previously stable and became unstable.
In this case, surgery in the last two weeks is a relative contraindication. That patient underwent a surgical thrombectomy and the resulting echo exam showed resolution of all of the secondary effects from the pulmonary embolus.
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The Role of Echocardiography Doppler in Pulmonary Embolism.