Signs Of Acute Pulmonary Embolism Research Articles

Case Report: Role of transesophageal echocardiography in a patient with an initially misdiagnosed acute pulmonary embolism

Background: For the diagnosis of acute pulmonary embolism, chest computerized tomography (CT) angiography is considered as the gold standard. However, echocardiography could be useful especially in cases of high suspicion with normal CT scan or for patient with hemodynamic instability. Case presentation: We present a case of a 47-year-old man admitted to the intensive care unit with a diagnosis of respiratory failure and hemodynamic instability 24 hours after closed fracture of the right leg. Before his admission, a thoracic CT angiography was done but did not show any sign of acute pulmonary embolism. During the first hours, he presented a bad evolution with a respiratory status which failed to respond to high dose of vasopressor, oxide nitric and ventilatory support. Therefore, due to the poor echocardiographic window, transesophageal echocardiography examination was done in emergency. It revealed high-probability diagnosis of massive pulmonary embolism based on right ventricular dysfunction and the presence of thrombus in the right pulmonary artery. Anticoagulant therapy (non-fractioned heparin) was administrated immediately achieving a favorable clinical outcome with rapid withdrawal of dobutamine, nitric oxide and norepinephrine. Conclusions: This case illustrates the fundamental role of transesophageal echocardiography in a critically ill patient with shock due to high-probability pulmonary embolism. Echocardiography allows the initiation of adequate treatment without further delay.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Abstract Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Abstract Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study.

We explored the variations in use of imaging modalities for confirming pulmonary embolism (PE) according to the trimester of pregnancy. We included all pregnant patients with confirmed acute PE from RIETE, a prospective registry of patients with PE (03/2001-02/2020). Imaging modalities included computed tomography pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scan, or presence of signs of acute PE along with imaging-confirmed proximal deep vein thrombosis (pDVT) without pulmonary vascular imaging. We compared the imaging modalities to postpartum patients with PE, and other non-pregnant women with PE. There were 157 pregnant patients (age: 32.7 ± 0.5), 228 postpartum patients (age: 33.9 ± 0.5), and 23,937 non-pregnant non-postpartum women (age: 69.5 ± 0.1). CTPA was the most common modality for confirming PE, from 55.7% in first trimester to 58.3% in second trimester, and 70.0% in third trimester. From first trimester to third trimester, V/Q scanning was used in 21.3%, 16.7%, and 18.3% of cases, respectively. Confirmed pDVT along with the presence of signs/symptoms of PE was the confirmatory modality for PE in 21.3% of patients in first trimester, 19.4% in second trimester, and 6.7% in third trimester. The proportion of postpartum patients confirmed with CTPA (85.5%) was comparable to that of non-pregnant non-postpartum women (83.2%). From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with PE diagnosed with CTPA (p = 0.039). CTPA was the primary modality for confirming PE in all trimesters of pregnancy, although its proportional use was higher in later stages of pregnancy. • Computed tomography pulmonary angiography (CTPA) was the primary modality of diagnosis in all trimesters of pregnancy among patients with confirmed pulmonary embolism, even in the first trimester. • From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with pulmonary embolism who were diagnosed based on CTPA. • In the postpartum period, use of CTPA as the modality to confirm pulmonary embolism was comparable to non-pregnant patients.

P1625Identification of chronic thromboembolic pulmonary hypertension on standard computed tomography pulmonary angiography for suspected acute pulmonary embolism

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed after a long delay, even though signs of CTEPH may already be present on the computed tomography pulmonary angiogram (CTPA) used to diagnose a preceding acute pulmonary embolism (PE). Diagnostic delay may be associated with worse prognosis. In this study we evaluated the diagnostic accuracy of extensive CTPA reading for predicting a future CTEPH diagnosis after acute PE. Method(s): Three expert radiologists scored radiological signs of CTEPH on CTPA performed for suspected acute PE in 50 PE patients who were subsequently diagnosed with CTEPH during follow-up with right heart catheterisation (cases), and in 50 PE patients, in whom sequential echocardiograms performed >2 years after the acute PE diagnosis had not shown any signs of pulmonary hypertension (controls). Cases and controls were matched on RV-to-LV ratio on baseline CTPA. Sensitivity and specificity of expert CTPA reading for predicting future CTEPH was calculated, and best predicting radiological parameters were identified by conditional backward multivariate analysis. Result(s): 75% of cases had signs of acute PE and 94% signs of chronic PE and/or PH. The overall expert adjudication yielded a sensitivity of 72% (95% CI 58-84%) and a specificity of 94% (95% CI 83-99%) for a future CTEPH diagnosis. We identified six objective, independent radiological predictors of CTEPH: intravascular webs, pulmonary artery retraction or dilatation, bronchial artery dilatation, right ventricle hypertrophy and interventricular septum flattening (Figure 1). The presence of >=3 of these parameters was associated with a sensitivity of 70% (95% CI 55-82%), a specificity of 96% (95% CI 86-100%) and a c-statistic of 0.92. Conclusion(s): In our cohort, expert radiologists identified 36 out of 50 PE patients with a future CTEPH diagnosis. The most probable explanation is that most of them already had CTEPH at the moment of the PE diagnosis. Our findings support the hypothesis that dedicated CTPA reading in patients with confirmed PE may lead to faster CTEPH diagnosis.

Pulmonary embolism associated with oral contraceptive use – Case report

A 25-year-old female patient with a history of oral contraceptive use was admitted to hospital because of exertional dyspnoea, palpitations, chest discomfort and weakness. Since the clinical presentation was suggestive of some heart disease the patient underwent echocardiography which revealed indirect signs of acute pulmonary embolism. The diagnosis was confirmed with multisliced computed tomography of the pulmonary arteries. Blood test results raised suspicion of antithrombin III deficiency. Enoxaparin and warfarin were used as treatment regimen with good effect and the patient was discharged home without significant symptoms, signs, and with normal echocardiography. CASE REPORT A 25-year-old female patient was admitted to hospital because of exertional dyspnoea, palpitations, chest discomfort and weakness. The symptoms had started about three weeks prior to hospital admission. The patient’s medical history was negative for significant disorders but the patient declared prolonged use of oral contraceptives. On physical examination, increased resting heart rate of about 140 per minute was found. ECG revealed sinus tachycardia without other abnormalities. The patient fainted and became pale in the face when trying to move from the bed. Since the clinical presentation was suggestive of some heart disease the patient underwent bedside echocardiography, and blood samples were taken for laboratory tests, including troponin T, N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) and D-dimer level. On echocardiography, indirect signs of acute pulmonary embolism were found including McConnell’s sign, dilatation of the right ventricle, shortening of pulmonary artery acceleration time with a typical notch on the spectrum, tricuspid regurgitation with TRVPG (tricuspid regurgitation peak gradient) about 70 mmHg. D-dimer level and NT-proBNP level were elevated. Troponin T level remained within normal range. Laboratory findings are shown in Table 1. The patient was sent for multisliced computed tomography of the pulmonary arteries and large clots were found within both branches of the main pulmonary artery (Fig. 1). Based on imaging, blood test results and clinical presentation, intermediate-risk pulmonary embolism was diagnosed in the patient. Pulmonary embolism is a rare disorder in young individuals without known risk factors for venous thromboembolism. Therefore, a blood sample was also taken for diagnosis of possible thrombophilia, including evaluation of antithrombin III, mutation of factor V Leiden, prothrombin, protein C, protein S and factor VIII. The level of antithrombin III was slightly lowered to about 77% of normal value. Since the patient was stable without signs or symptoms of haemodynamic compromise, low molecular weight heparin – enoxaparin – at a weight-adjusted dose of 1 mg/kg was administered subcutaneously twice daily. The patient’s state improved significantly within two days. After five days, the patient was administered orally the anticoagulant warfarin. No recurrent dyspnoea, fainting or bleeding as a side-effect of the treatment were observed. Echocardiographic measures as well as laboratory findings of heart failure returned to normal. The patient was discharged home safely with recommendation to keep taking warfarin for at least six months and to repeat antithrombin III level evaluation after the treatment. This was because the low values observed in the acute stage of the disease could be the result of ongoing thrombosis.

Can isolated ST elevation in aVR lead be a sign of acute pulmonary embolism?

Can isolated ST elevation in aVR lead be a sign of acute pulmonary embolism?

Widening of coronary sinus in CT pulmonary angiography indicates right ventricular dysfunction in patients with acute pulmonary embolism

Right ventricular dysfunction (RVD) may occur in the course of acute pulmonary embolism (PE). Patients with RVD need more intensive treatment, and the prognosis is more severe. The aim of this study was to evaluate the usefulness of the measurement of the coronary sinus in the assessment of RVD in patients with acute PE and to compare it with other indicators of RVD. Retrospective assessment of 55 CT pulmonary angiography examinations with signs of acute PE was performed. Pulmonary artery systolic pressure (PASP) was echocardiographically assessed in all patients, and RVD was defined as PASP values greater than 30 mmHg. CT measurements included the size of the heart ventricles, mediastinal vessels and the width of the coronary sinus. Median width of the coronary sinus was 16 mm (range 12-24 mm) in patients with increased PASP and 10 mm (range 7-22 mm) in patients with normal PASP (p = 0.001). Best cut-off value was assessed to be 12.5 mm, with sensitivity 94% and specificity 75%. It was characterised by the largest area under ROC curve (0.82) among analysed parameters. Width of the coronary sinus seems to be a promising parameter for identification of RVD in patients with acute PE. A prospective study should be undertaken to further assess its clinical and prognostic applicability.

Acute Right Bundle Branch Block as a Presenting Sign of Acute Pulmonary Embolism

To the Editor: Rosenberger et al. (1) described the limited utility of intraoperative transesophageal echocardiography (TEE) as a primary diagnostic tool for obtaining a definitive diagnosis of pulmonary embolism (PE). We wish to highlight the role of the electrocardiogram (ECG) in diagnosing PE. A 51-yr-old patient presented to the operating room for reduction of a hip dislocation. The patient's preoperative ECG, obtained earlier the same day, revealed sinus bradycardia (Fig. 1). Immediately before a planned induction of general anesthesia, we attached an ECG monitor and noted a new right bundle branch block (RBBB). We postponed induction and obtained a 12-lead ECG in the operating room (Fig. 2). The ECG revealed new findings, including normal sinus rhythm, (RBBB), multiple ST segment abnormalities, S1Q3T3 pattern, and T wave inversion V1-V3. A subsequent computerized tomography (CT) scan revealed multiple, deep-venous thrombi and massive PE.Figure 1.: Preoperative electrocardiogram obtained 12 hours prior to planned surgery. Sinus bradycardia.Figure 2.: Electrocardiogram obtained in the operating room. Normal sinus rhythm, right bundle branch block, multiple ST segment abnormalities, S1Q3T3 pattern, and T wave inversion V1-V3.The usefulness of ECG findings in the diagnosis of PE is controversial (1). As with clinical presentation and physical examination, an ECG is of limited value in diagnosing PE: findings are often inconsistent and nonspecific (1). ECG changes may vary with the size of the embolus, impact upon hemodynamics, and cardiopulmonary reserve (1,2). Classically described findings are often absent, or they are equally prevalent in patients suspected of having PE in whom an alternative diagnosis is ultimately made (2). Although approximately 90% of patients with PE have at least one abnormality on ECG, many of these findings are nonspecific and therefore limited in their diagnostic utility in cases of suspected PE (3). Given the widespread use of imaging modalities for diagnosis of PE, the primary function of the ECG in modern clinical practice is to raise or reinforce suspicion (4). In our case it was a new RBBB, indicative of impairment in right-sided cardiac conduction, that prompted further evaluation. Its significance for diagnosing PE is unclear. One study found new RBBB in 80% of patients with massive trunk embolism but in no cases of peripheral embolism in the pulmonary artery (4). Another study found RBBB present in 10% of patients with confirmed PE, although the severity of PE failed to correlate with the presence or absence of RBBB (5). In that same study, a pattern of subepicardial ischemia (T-wave inversions) in the precordial leads was the finding most often noted in PE and also the finding most closely correlated with severity. Inverted T-waves, however, present in many other processes, are thus of limited diagnostic utility. In another study, 28 different ECG abnormalities were analyzed in patients suspected of having PE who presented for imaging studies (2). Only tachycardia (42%) and incomplete RBBB (7%) occurred significantly more often in patients who were confirmed by imaging to indeed have PE than patients with other etiologies. In the same study complete RBBB was found in only 4% of cases of confirmed PE, and it was not diagnostic. Even the classic S1Q3T3 pattern, with a reported prevalence of 12% in massive PE, may occur frequently enough in patients falsely suspected of having PE so as to limit its usefulness as a diagnostic criterion (2,5,6). Statistical analysis is complicated by the numerous possible combinations of findings that may exist on any given ECG. Given that the ECG alone is of limited value in the diagnosis of PE, clinicians must consider the clinical presentation in its entirety (7). Typically, it is prudent to pursue confirmatory imaging studies, such as a CT scan, before proceeding with definitive treatment for PE. The article by Rosenberger et al. indicates that TEE lacks the sensitivity to play this role. The most important role of the ECG is to trigger further evaluation that can lead to definitive diagnosis and prompt treatment of this life-threatening condition. Greg Ginsburg, MD Neelakantan Sunder, MD Priscilla Grace Harrell, MD Department of Anesthesia and Critical Care Massachusetts General Hospital Boston, Massachusetts [email protected]

Diagnostik und Therapie der Lungenembolie

Management of venous thromboembolism has long been characterized by a high degree of complexity and a disappointing lack of both efficacy and efficiency. The non-specific clinical signs of acute pulmonary embolism (PE) and the limitations of earlier imaging procedures such as the lung scan and pulmonary angiography led to the development of numerous sophisticated, multi-step diagnostic algorithms which, however, have proved extremely difficult to implement in clinical practice. As a result, the diagnosis of potentially life-threatening PE was frequently missed in many patients who subsequently died of the disease without receiving appropriate treatment, while other patients unnecessarily underwent a battery of invasive, time consuming procedures due to a vague, poorly documented clinical suspicion. Recently, the development of structured models for assessment of clinical pre-test probability, the widespread use of D-dimer testing in the outpatient setting, and particularly the technical advances of multidetector-row CT scan, had an enormous impact on our strategy for approaching patients with suspected PE. Contemporary diagnostic algorithms based on the above modalities are not only efficient and reliable but also simple and practicable. Furthermore, the importance of right ventricular (RV) dysfunction, even in the absence of overt hemodynamic instability, was recognized, and a number of studies demonstrated the value of echocardiography and laboratory biomarkers for risk stratification of PE. At present, low molecular weight heparins are increasingly becoming established as the treatment of choice for hemodynamically stable patients without RV dysfunction (non-massive PE), while consensus exists that patients with massive PE and cardiogenic shock necessitate emergency removal of pulmonary thrombus using thrombolytic agents, surgical embolectomy, or catheter-based thrombus aspiration. On the other hand, the treatment of stable patients with RV dysfunction (submassive PE) remains the subject of debate, and a large randomized trial is urgently needed to address the possible clinical benefits of thrombolysis in this setting.

Reperfusion Pulmonary Edema after the Removal of Hepatocellular Carcinoma Embolus

To report a non-fatal case of reperfusion pulmonary edema (RPE) after the removal of a hepatocellular carcinoma embolus, which had caused an acute obstruction of the tricuspid valve and pulmonary vasculature during a hepatic lobectomy. Pulmonary embolism caused by hepatocellular carcinoma embolus is extremely rare, and, in the present case, it was associated with unusual clinical features. A 69-year-old ASA II woman with hepatocellular carcinoma was presented for an elective left hepatic lobectomy. During the surgery, the tumor embolus was dislodged from the interior of the lumen of the inferior vena cava (IVC), which then drifted into the tricuspid valve area and pulmonary vasculature. The patient showed the specific signs of acute pulmonary embolism, such as a reduction in end-tidal carbon dioxide, an increase in central venous pressure, and a decrease in arterial pressure. The patient exhibited the symptoms for about 10 minutes. After this period, however, cardiovascular variables became relatively stable, even during a mechanical obstruction due to cross-clamping the pulmonary artery for embolectomy. After several hours of pulmonary embolectomy, the patient experienced an episode of RPE. The ventilatory supports for the treatment of RPE were successful, and the patient recovered without any complications. The patient's case in the present study demonstrates that pulmonary embolism may occur as a result of a hepatocellular carcinoma extending into the IVC during operative management. The anesthesiologist should be careful of the possibilities of RPE after removal of the tumor embolus.

Frequency of plain film abnormalities and some clinical findings of acute pulmonary embolism – correlation with severity of pulmonary arterial obstruction

Background: The aim of the study was to find out if chest x-ray abnormalities and some clinical signs and findings in patients with acute pulmonary embolism (PE) correlate with the degree of pulmonary arterial obstruction (CT obstruction index – CTOI) determined with scoring system on spiral CT angiograms (SCTA). Material and methods: In 41 pts (16 men, 25 women; age range 20–89 years, mean 65 years) with SCTA proven acute PE, plain chest films were retrospectively reviewed for signs of acute PE. A scoring system based on site and degree of arterial obstruction enabled measurement of severity of obstruction on SCT angiograms. Some clinical signs (sudden onset dispnea, chest pain, syncope), ECG, pH and pCO2 of arterial blood were evaluated and compared between group with major PE (10 pts with CTOI > 40%) and the rest (31 pts with CTOI 40% (60% vs. 22.5%; p value < 0.05). There was no difference in frequency of clinical signs, pH and pCO2 of arterial blood between patients with major and minor PE. Conclusions: In pts with CT proven acute PE, oligemia on chest x-ray and ECG signs of right ventricular strain correlate with severity of pulmonary arterial obstruction. Clinical simptoms, pH and pCO2 of arterial blood show no correlation with degree of pulmonary arterial obstruction.

Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism

Transthoracic echocardiography (TTE) is frequently performed in patients with suspected acute pulmonary embolism (APE) to search for right ventricular (RV) pressure overload. We prospectively assessed the diagnostic value of a new Doppler echocardiographic sign of APE based on the disturbed RV ejection pattern (“60/60 sign”) and compared its diagnostic performances with that of the presence of RV pressure overload, as well as with “McConnell sign” based on RV regional wall motion abnormalities. We assessed 100 consecutive patients with clinical suspicion of APE, including those with previous cardiorespiratory diseases. After TTE, all of the patients underwent reference diagnostic tests for APE. The 60/60 sign required RV acceleration time of ≤60 ms in presence of tricuspid insufficiency pressure gradient ≤60 mm Hg. APE was ultimately confirmed in 67 of 100 patients. In 17 of 67 patients, 60/60 sign correctly suggested APE, whereas 2 false-positive results were noted: in pulmonary fibrosis and in acute respiratory distress syndrome following lung resection. McConnell sign was fully specific but was noted in only 13 of 67 patients. Sensitivity and specificity were 81% and 45% for “RV-pressure overload” signs, 25% and 94% for 60/60 sign, and 19% and 100% for McConnell sign. When combined, the 2 latter signs were 94% specific and 36% sensitive in diagnosing APE. Thus, RV overload at echocardiography is not specific for APE. The 60/60 and McConnell signs are insensitive, but are reliable and helpful in bedside diagnosis of APE when direct visualization of the pulmonary arteries is impossible. Combining these 2 signs may increase the sensitivity without compromising the specificity of echocardiographic diagnosis of APE.

From not detected pulmonary embolism to diagnosis of chronic thromboembolic pulmonary hypertension: a retrospective study.

The past and present clinical history of 13 patients with hemodynamic and angiographic diagnosis of chronic thromboembolic pulmonary hypertension (CTPH) was reviewed in order to investigate the reasons for failure of resolution of acute pulmonary embolism (PE) and findings useful for diagnosis of CTPH. All patients had chest radiograph, ECG, arterial blood gas analysis and pulmonary perfusion scintigraphy performed. Clinical assessment demonstrated that no patient had diagnosis and treatment of the several retrospectively identified episodes of PE (from 1 to 8); the lack of diagnosis was due to underestimation of symptoms and signs such as dyspnea (85%), pleuritic chest pain (31%) or phlebitis (46%) that were present months or years earlier. Alternative diagnoses erroneously made were dyspnea of unknown origin (5 cases), left heart failure (4 instances) and pneumonia (2 cases). Once CTPH has developed, chronic dyspnea (92%) and substernal chest pain (100%) are almost always present: chest radiograph and ECG show signs of chronic hypertension such as enlargement of hila (100%), right heart sections (77%), azygos vein (46%) and P pulmonale (67%), T inversion on right precordial leads (75%), S-T segment depression (75%), respectively. Perfusion scintigraphy shows severe perfusion impairment (55.7% of the total vascular bed) paralleled by severe hypoxia (standard PaO2 = 49 +/- 14.1 mm Hg). In conclusion, patients with PE who develop CTPH are not diagnosed and thus untreated because clinical symptoms and signs of acute PE have not been recognized. If CTPH develops, clinical assessment (including simple and noninvasive techniques such as chest radiograph, ECG and blood gas analysis) may show a quite characteristic pattern useful for diagnosis.