Kurnicka et al identified changes on transthoracic echocardiography (TEE) associated with an acute pulmonary embolism. Most patients with pulmonary emboli show either no significant or only incidental changes on TEE but a subset show hemodynamic instability. The authors are from the Medical University of Warsaw.
Patient selection: suspected acute pulmonary embolism
Hemodynamic instability associated with pulmonary embolism - both of the following:
(1) one or both of the following:
(1a) systolic blood pressure < 90 mm Hg
(1b) need for vasopressors
(2) exclusion of conditions other than pulmonary embolism (sepsis, hypovolemia, etc)
Standard definition for right ventricular dysfunction - both of the following:
(1) hypokiness of the free wall of the right ventricle
(2) right ventricle to left ventricle end-diastolic ratio > 0.9 in the 4-chamber apical view
Typical echocardiographic signs of acute pulmonary embolism (TES):
(1) McConnell sign
(2) 60/60 sign
(3) right heart thrombus
McConnell sign - both of the following:
(1) hypokinesis of the free wall of the right ventricle
(2) normal contraction of the apical segment of the right ventricle
60/60 sign - both of the following:
(1) pulmonary ejection acceleration time (AcT) < 60 msec (shortening) with "notch" (midsystolic velocity deceleration) in the right ventricular outflow tract (proximal to the pulmonary valve)
(2) tricuspid regurgitation peak systolic gradient (TRPG) < 60 mm Hg
All patients with pulmonary embolism and hemodynamic instability had:
(1) an enlarged and hypokinetic right ventricle
(2) one or more TES
Not all patients with pulmonary embolism and hemodynamic instability met the criterion for right ventricle to left ventricle end-diastolic ratio > 0.9 in the 4-chamber apical view.
