Value Of Transthoracic Echocardiography In Diagnosis, Therapy Regimens Evaluation, And Prognosis In Acute Pulmonary Thromboembolism

Objective To evaluate the diagnostic value of right ventricular dysfunction (RVD) on transthoracic echocardiography (TTE) combined with deep venous thrombosis (DVT) on lower-limb venous ultrasonography in patients with acute pulmonary thromboembolism (PTE).Methods This prospective multicenter control trial included 520 patients with confirmed acute PTE from 41 hospitals between June 2002 and February 2005. All the patients were divided into two groups: Group I—250 patients with major PTE; Group II—270 patients with minor PTE. All the patients were evaluated by TTE and lower-limb venous ultrasonography within 24 hours from randomization. The echocardiographic criteria of acute RVD included at least two of the following. (1) right ventricular dilatation: right and left ventricular end-diastolic diameter ratio in the parasternal long-axis view (RVED/LVED) >0.6 or right /left ventricular end-diastolic diameter ratio in four-chamber view (RV/LV) >1.1 or right /left atrial diameter ratio (RA/LA) >1.1; (2) right ventricular wall motion (RVWM)< 5mm; (3) loss of inspiratory collapse of inferior vena cava (IVC); (4) Tricuspid regurgitant pressure gradient (TRPG) >30mmHg, which was calculated from tricuspid regurgitant jet velocity. Systolic pulmonary artery pressure (SPAP) was measured using the following equation: SPAP was 4 × (peak tricuspid regurgitant velocity)~2 + right atrial pressure (RAP). RAP was estimated according to the respiratory motion of IVC. However, these signs of RVD were not considered acute in the presence of right ventricular wall hypertrophy (free wall thickness >5mm). Results We investigated the diagnostic value of combined sign of RVD plus DVT. The incidence of RVD and DVT was associated with the severity of PTE (p<0.001). There were 248 patients (56.0%) with RVD in 443 patients with TTE , 213 patients (49.1%) with DVT in 434 patients with lower-limb venous ultrasonography. In all the 363 patients with TTE and lower-limb ultrasonography, 207(57.0%) patients with RVD, 180 (49.6%) patients with DVT, 265 patients (73.0%) with RVD and/or DVT, and 121 patients (33.3%) with combined sign of RVD plus DVT in the whole population. As to 207 major PTE patients, 206 patients (99.5%) had RVD and 121 patients (58.5%) had DVT. 206 (99.5%) patients with RVD and/or DVT and 120 (58.0%) patients with combined sign of RVD plus DVT. In addition, the rate of positive RVD was much greater in proximal PTE than in lobar PTE and segmental PTE (78.7%, 51.4% and 21.7% respectively, p<0.001). DVT occurred more frequently in proximal PTE than in lobar PTE and segmental PTE (61.7%, 46.8% and 37.0% respectively, p<0.001). The incidence of the combined sign was much higher in proximal PTE than in lobar PTE and segmental PTE (51.1%, 24.3% and 8.7% respenctively, P<0.001).Conclusions The incidence of the combined sign of RVD plus DVT was associated with the severity of PTE and the localization of emboli. The combined sign of RVD plus DVT help diagnose major PTE especially in emergency department. This combined ultrasound method provided a simple and reliable bedside means for us to solve "gray zone" in diagnosis strategy. We would give great regard to those patients with positive RVD plus DVT and reduce time interval before optimal therapy, which was critical to lower mortality in acute PTE. Background: Acute pulmonary thromboembolism (PTE) causes right ventricular dysfunction (RVD). PTE patients with and without RVD can benefit from thrombolytic therapy or anticoagulants. In this study, we assessed the changes of right ventricular (RV) function on transthoracic echocardiography (TTE) after different therapy strategies among a broad spectrum of PTE.Methods: The present prospective randomized trial included 516 PTE patients from 41 hospitals in China between June 2002 and February 2005. Patients were divided into two groups at presentation: group I (major PTE) —50 patients with hemodynamic instability and 196 normotensive patients with RVD; group II (minor PTE) —270 normotensive patients without RVD. The patients in group I were randomly divided into four subgroups according to different thrombolytic regimens: A-- urokinase 12h subgroup; B--urokinase 2h subgroup; C--recombinant tissue-type plasminogen activator (rtPA) 50mg subgroup and D-- rtPA 100mg subgroup; Different anticoagulants were randomly assigned to patients in group II: NA--heparin subgroup; NB-- nadroparin subgroup. TTE were performed before the therapy, and 24 hours, 14 days and 3 months after the therapy, respectively. The echocardiographic criteria of acute RVD included at least two of the following. (1) right ventricular dilatation: right and left ventricular end-diastolic diameter ratio in the parasternal long-axis view (RVED/LVED) >0.6 or right /left ventricular end-diastolic diameter ratio in four-chamber view (RV/LV) >1.1 or right /left atrial diameter ratio (RA/LA) >1.1; (2) right ventricular wall motion (RVWM)< 5mm; (3) loss of inspiratory collapse of inferior vena cava (IVC); (4) Tricuspid regurgitant pressure gradient (TRPG) >30mmHg, which was calculated from tricuspid regurgitant jet velocity.Results: Mean age was 57.4±14.1 years and 323 patients (62.6%) were male. The indexes of RV function on TTE in group I were significantly improved compared with those in group II at each point (p<0.05) and SPAP decreased after anticoagulants administration in group II. However, there was no difference among thrombolytic subgroups in group I and between the two anticoagulants subgroups in group II. The presence of RVD was much lower (34.0% vs 100%, p<0.001) 24 hours after thrombolytic therapies than that before the therapy in group I, which documented that thrombolytic agents early reversed RVD in major APE patients. Even 3 months after the therapy, TRPG and SPAP were still higher in group I than those in group II.Conclusions: TTE documented the identical effect of thrombolytic regimen of urokinase 12h, urokinase 2h, rtPA 50mg and rtPA 100mg in major APE which suggest rtPA 100mg can supersede rtPA 50mg in these patients. Heparin produced the similar results compared with nadroparin in minor APE. TTE can monitor the effect of thrombolysis early and identify the patients with persistent pulmonary hypertension which possibly develope chronic thromboembolic pulmonary hypertension. Therefore, it can faciliate the management of PTE. Background: Acute pulmonary thromboembolism (PTE) patients with right ventricular dysfunction (RVD) who may benefit from thrombolytic therapy have a worse prognosis. We assessed RVD in prognosis and constructed a prognostic model, deciding the indexes correlating best with prognosis.Methods: The prospective study included 520 consecutive acute PTE patients from 41 hospitals in China between June 2002 and February 2005. All the patients were evaluated by TTE, CTPA, laboratory tests, and blood gas analysis. The doctors recorded their clinical manifestations. The echocardiographic criteria of acute RVD included at least two of the following. (1) right ventricular dilatation: right and left ventricular end-diastolic diameter ratio in the parasternal long-axis view (RVED/LVED) >0.6 or right /left ventricular end-diastolic diameter ratio in four-chamber view (RV/LV) >1.1 or right /left atrial diameter ratio (RA/LA) >1.1; (2) right ventricular wall motion (RVWM)< 5mm; (3) loss of inspiratory collapse of inferior vena cava (IVC); (4) Tricuspid regurgitant pressure gradient (TRPG) >30mmHg. Univariate analysis demonstrated the parameters correlated with an adverse 14-day clinical outcome. A multiple logistic regression analysis decided independent predictors and constructed a prognostic model.Results: Mean age was 57.4±14.1 years and 323 patients (62.1%) were male. The 14-day mortality in normotensive patients with RVD was higher (2.0% vs 0.4%, P<0.01) than without RVD. ROC curve showed the best cut-off values of RVED/LVED and SPAP for 14-day prognosis were 0.67 and 60mmHg, respectively. SPAP independently predicted 3-month clinical outcomes (p<0.01). Univariate analysis demonstrated 24 parameters correlated with an adverse 14-day clinical outcome as follow: palpation ,Syncope, panic , cyanosis, respiratory rate≥30 /min, pulse≥110 /min, jugular vein, accentuation of P2, murmurs in tricuspid area, time interval from onset, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), alveolar-arterial PO2 difference (PA-aO2), white blood cell (WBC) <4000/L or >100000/L, platelet , thrombus on TTE , RV/LV>1.1, TRPG>30mmHg , IVCmin<8mm, RVD, RVED/LVED>0.6, SPAP>60mmHg, RVWM, PTE range larger than two lobes or seven segments on CTPA. Furthermore, a multiple logistic regression model implied 8 predictors including RVD , RVED/LVED>0.6, SPAP>60mmg, pulse≥110 /min, accentuation of P2, Syncope, CPK, WBC <4000/L or >100000/L be independent predictors of an adverse 14-day clinical outcome (p<0.01). This model fit well (P<0.0001). We choose a cut-off value of P≥0.2 and compared the model and the original derivation samples. The results showed that sensitivity (true positive rate) was 81.82%, specificity 92.11%, false positive rate18.18%, coincidence 91.14%, and concordance rate 80.96%.Conclusions: RVD was a discriminator for a poor prognosis in normotensivepatients. Early detection of RVD (especially RVED/LVED>0.67 and/or SPAP>60 mmHg) was beneficial for identifying high-risk patients. A multiple logistic regression model implied 8 predictors including RVD, RVED/LVED>0.6, SPAP>60mmg, pulse≥110 /min, accentuation of P2, Syncope, CPK, and WBC <4000/L or >100000/L be independent predictors of an adverse 14-day clinical outcome (p<0.01). This model fit well (P<0.0001).