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| Home->COTW AMA Category 1 Credit for Physicians Only. ASRT CME is not available. |
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Case-of-the-Week Information
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The echocardiographic findings in this patient are: A mass in the pulmonary artery Right Ventricular Dilation Right Ventricular Hypokinesis Tricuspid Regurgitation Pulmonary Hypertension 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 Pulmonary Regurgitation Hepatic Vein Doppler Systolic Reversal Small Left Atrium Small Left Ventricle Pleural Effusion Other diseases that may simulate this patient's symptoms are: Acute Myocardial Ischemia Acute Myocardial Infarction Pericardial Effusion/Tamponade Pneumothorax Fat Embolus Atrial Fibrillation Aortic Stenosis Cor Pulmonale The tests that could be ordered are: Pulmonary Angiogram Computed Tomographic Angiography (CTA) MRI V/Q Scan Echocardiogram 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 Thrombolysis Thrombectomy IVC Filter 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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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.
This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.
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