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Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest☆,☆☆ Abstract Pulmonary embolism remains toward the top of a clinician's differential on any patient who presents with chest pain or dyspnea. Diagnosis of a pulmonary embolism is usually determined by computed tomography angiogram of the chest. We present a case of a patient who presented with acute dyspnea and was diagnosed with a saddle pulmonary embolism visualized on point-of-care cardiac ultrasound later confirmed by computed tomography angiogram of the chest. We also describe the common ultrasound findings on a transthoracic echocardiogram of a patient with saddle pulmonary embolism and right ventricular dysfunction. A 33-year-old woman with a medical history of mild intermittent asthma, Sjögren syndrome, migraines, and gastroesophageal reflux disease presented to the emergency department (ED) for 1 week of shortness of breath not relieved with her albuterol meter-dose inhaler. Her blood pressure was 130/91, heart rate was 103, and her respiratory rate was 22. Her lungs were clear to auscultation with no prolonged expirations, and her heart sounds were normal. The patient was given albuterol, ipratropium, and prednisone with no improvement in her symptoms. Blood work revealed a significantly elevated D-dimer. The emergency physician performed a point-of-care cardiac sonogram that revealed echocardiographic signs of right heart strain. The sonogram revealed a dilated right ventricle (RV), RV hypokinesis with apical sparing on apical 4-chamber view, and flattening of the ventricular septum on parasternal short-axis view. While remaining in the parasternal shortaxis view of the heart, the ultrasound probe was fanned cephalad to reveal the pulmonary trunk with visible thrombus straddling the bifurcation of the pulmonary trunk (Fig. 1) (Video 1 in the online version at http://dx.doi.org/10.1016/j.ajem.2016.06.037). The patient was transferred to the critical care side of the ED and had a computed tomography (CT) angiogram of the chest confirming a saddle embolus (Fig. 2). Discussion was made with the patient about the use of thrombolytic therapy, and because she was hemodynamically stable, she was ultimately started on Lovenox and was admitted to the hospital. Patient had an uneventful hospital course and was discharged on day 6 with Apixaban. Saddle pulmonary embolism (PE) is defined as a visible thromboembolus straddling the bifurcation of the right and left pulmonary trunk and has a frequency of between 2.6% and 5.2% in all patients
☆ Sources of support or funding: None. ☆☆ Ultrasound equipment used: Philip Sparq.
with PE [1,2]. Physicians are concerned about saddle PEs because they carry a 2-week mortality risk of 5.8% [3]. Transthoracic echocardiography (TTE) has high utility for clinicians in the setting of PE. Transthoracic echocardiography can help the clinician determine the presence or absence of RV dysfunction (RVD) and can easily be performed at the patient bedside. The diagnosis of PE plus the presence of RVD on TTE is a well-known predictor of impending shock and inhospital mortality. A prospective study performed by Grifoni et al [4] ascertained that 10% of normotensive patients with acute PE and RVD later developed PErelated shock and had 5% inhospital mortality compared to those patients with acute PE and no RVD. Evaluation of the pulmonary trunk is best visualized in the parasternal short-axis view with the probe fanned in a more cephalad position looking at the base of the heart. Visualization of thrombus in the pulmonary trunk or its main branches may be difficult to visualize for many clinicians and is most likely not from technique but more notably from poor echocardiographic windows, such as patient body habitus or by respiratory movement of the left lung. Because visualization of the pulmonary trunk may be difficult, clinicians may look for thrombus elsewhere in the chambers of the right heart or for other signs of RVD. In a meta-analysis performed by Torbicki et al [5], visualization of a right heart thrombus carries a mortality that is twice as high (14-day mortality of 21% vs 11%) compared to those without a visualized right heart thrombus. Moreover, in the setting of acute PE, visualization of RVD on TTE will be more evident than actual visualization of thrombus. The ability to differentiate RVD from an acute cause, such as a PE as in this case, from a more chronic cause such as pulmonary hypertension or cor pulmonale from long-standing chronic obstructive pulmonary disease will require the clinician to perform more echocardiographic measurements. An RV wall thickness of greater than 5 mm is more likely from a chronic rather than acute cause [6]. Evidence of RVD on echocardiography has been shown to have adverse effects on clinical outcome on patients with PEs [1]. Ryu et al [2] found that when echocardiography is performed within 48 hours of a patient with saddle PEs, echocardiography had revealed mild-tomoderate RV enlargement in 90% and mild-to-severe RV dysfunction in 80% of the cases. There are multiple ultrasound findings of RVD secondary to PE on TTE. The more common and easily identifiable ultrasound findings are RV enlargement with an RV/left ventricle (LV) ratio greater than 1:1 (normal RV:LV ratio is 0.6:1); RV hypokinesis with sparing of right apex, referred to as a McConnell sign; and flattening or bowing of the ventricular septum into the LV, referred as a “D” sign [6,7]. Other
0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Secko M, et al, Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.06.037
2
M. Secko et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. A parasternal short-axis view of the heart. The pulmonary artery (PA) is outlined and lies adjacent to the aortic valve (AV). Arrow denotes echogenic thrombus overlying the bifurcation of the pulmonary artery.
ultrasound findings include right atrial or pulmonary artery dilation, right heart thrombus or thrombus in-transition, and moderate to severe tricuspid regurgitation on Doppler [6,7]. The diagnostic accuracy of RVD on TTE to diagnosis PE ranges and depends on sonographer experience. The reported sensitivity is 32% to 93% with specificity of 82% to 98% [4,8–12] for TTE to diagnose PE. In conclusion, point-of-care cardiac ultrasound (TTE) should be considered and used in all patients with diagnosed or suspected of having a PE, particularly a saddle embolus as the ultrasound will help determine the severity and ultimately guide further management of this disease process. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2016.06.037.
Michael Secko MD, RDMS⁎ Eric Legome MD Stephan Rinnert MD Department of Emergency Medicine SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203 ⁎ Corresponding author. Department of Emergency Medicine SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203 Tel.: +1 631 645 7200; fax: +1 631 239 1754 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2016.06.037
References [1] Musani MH. Asymptomatic saddle pulmonary embolism: case report and literature review. Clin Appl Thromb Hemost 2011;17(4):337–9. [2] Ryu JH, Pellikka PA, Froehling DA, Peters SG, Aughenbaugh GL. Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome. Respir Med 2007;101(7):1537–42. [3] Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136(9):691–700. [4] Grifoni S, Olivotto I, Cecchini P, Pieralli F, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000;101(24):2817–22. [5] Torbicki A, Galie N, Covezzoli A, Rossi E, et al. Right heart thrombi in pulmonary embolism. Results from the international cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245–51. [6] Rudski LG, Lai WW, Afilalo J, Hua L, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685–713. [7] Rudoni RR, Jackson RE, Godfrey GW, Bonfiglio AX. Use of two-dimensional echocardiography for the diagnosis of pulmonary embolus. J Emerg Med 1998;16(1):5–8. [8] Dresden S, Mitchell P, Rahimi L, Leo M, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med 2014;63(1):16–24. [9] Perrier A, Tamm C, Unger PF, Lerch R, Sztajzel J. Diagnostic accuracy of Dopplerechocardiography in unselected patients with suspected pulmonary embolism. Int J Cardiol 1998;65(1):101–9. [10] Miniati M, Monti S, Pratali L, Di Ricco G, et al. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Am J Med 2001;110(7):528–35. [11] Nazeyrollas P, Metz D, Jolly D, Maillier B, et al. Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism. Eur Heart J 1996;17(5):779–86. [12] Nazerian P, Vanni S, Volpicelli G, Gigli C, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014;145(5): 950–7.
Fig. 2. Computed tomography angiogram of the chest at the level of the pulmonary bifurcation. Two arrows delineate the saddle embolus.
Please cite this article as: Secko M, et al, Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.06.037
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest☆,☆☆ Abstract Pulmonary embolism remains toward the top of a clinician's differential on any patient who presents with chest pain or dyspnea. Diagnosis of a pulmonary embolism is usually determined by computed tomography angiogram of the chest. We present a case of a patient who presented with acute dyspnea and was diagnosed with a saddle pulmonary embolism visualized on point-of-care cardiac ultrasound later confirmed by computed tomography angiogram of the chest. We also describe the common ultrasound findings on a transthoracic echocardiogram of a patient with saddle pulmonary embolism and right ventricular dysfunction. A 33-year-old woman with a medical history of mild intermittent asthma, Sjögren syndrome, migraines, and gastroesophageal reflux disease presented to the emergency department (ED) for 1 week of shortness of breath not relieved with her albuterol meter-dose inhaler. Her blood pressure was 130/91, heart rate was 103, and her respiratory rate was 22. Her lungs were clear to auscultation with no prolonged expirations, and her heart sounds were normal. The patient was given albuterol, ipratropium, and prednisone with no improvement in her symptoms. Blood work revealed a significantly elevated D-dimer. The emergency physician performed a point-of-care cardiac sonogram that revealed echocardiographic signs of right heart strain. The sonogram revealed a dilated right ventricle (RV), RV hypokinesis with apical sparing on apical 4-chamber view, and flattening of the ventricular septum on parasternal short-axis view. While remaining in the parasternal shortaxis view of the heart, the ultrasound probe was fanned cephalad to reveal the pulmonary trunk with visible thrombus straddling the bifurcation of the pulmonary trunk (Fig. 1) (Video 1 in the online version at http://dx.doi.org/10.1016/j.ajem.2016.06.037). The patient was transferred to the critical care side of the ED and had a computed tomography (CT) angiogram of the chest confirming a saddle embolus (Fig. 2). Discussion was made with the patient about the use of thrombolytic therapy, and because she was hemodynamically stable, she was ultimately started on Lovenox and was admitted to the hospital. Patient had an uneventful hospital course and was discharged on day 6 with Apixaban. Saddle pulmonary embolism (PE) is defined as a visible thromboembolus straddling the bifurcation of the right and left pulmonary trunk and has a frequency of between 2.6% and 5.2% in all patients
☆ Sources of support or funding: None. ☆☆ Ultrasound equipment used: Philip Sparq.
with PE [1,2]. Physicians are concerned about saddle PEs because they carry a 2-week mortality risk of 5.8% [3]. Transthoracic echocardiography (TTE) has high utility for clinicians in the setting of PE. Transthoracic echocardiography can help the clinician determine the presence or absence of RV dysfunction (RVD) and can easily be performed at the patient bedside. The diagnosis of PE plus the presence of RVD on TTE is a well-known predictor of impending shock and inhospital mortality. A prospective study performed by Grifoni et al [4] ascertained that 10% of normotensive patients with acute PE and RVD later developed PErelated shock and had 5% inhospital mortality compared to those patients with acute PE and no RVD. Evaluation of the pulmonary trunk is best visualized in the parasternal short-axis view with the probe fanned in a more cephalad position looking at the base of the heart. Visualization of thrombus in the pulmonary trunk or its main branches may be difficult to visualize for many clinicians and is most likely not from technique but more notably from poor echocardiographic windows, such as patient body habitus or by respiratory movement of the left lung. Because visualization of the pulmonary trunk may be difficult, clinicians may look for thrombus elsewhere in the chambers of the right heart or for other signs of RVD. In a meta-analysis performed by Torbicki et al [5], visualization of a right heart thrombus carries a mortality that is twice as high (14-day mortality of 21% vs 11%) compared to those without a visualized right heart thrombus. Moreover, in the setting of acute PE, visualization of RVD on TTE will be more evident than actual visualization of thrombus. The ability to differentiate RVD from an acute cause, such as a PE as in this case, from a more chronic cause such as pulmonary hypertension or cor pulmonale from long-standing chronic obstructive pulmonary disease will require the clinician to perform more echocardiographic measurements. An RV wall thickness of greater than 5 mm is more likely from a chronic rather than acute cause [6]. Evidence of RVD on echocardiography has been shown to have adverse effects on clinical outcome on patients with PEs [1]. Ryu et al [2] found that when echocardiography is performed within 48 hours of a patient with saddle PEs, echocardiography had revealed mild-tomoderate RV enlargement in 90% and mild-to-severe RV dysfunction in 80% of the cases. There are multiple ultrasound findings of RVD secondary to PE on TTE. The more common and easily identifiable ultrasound findings are RV enlargement with an RV/left ventricle (LV) ratio greater than 1:1 (normal RV:LV ratio is 0.6:1); RV hypokinesis with sparing of right apex, referred to as a McConnell sign; and flattening or bowing of the ventricular septum into the LV, referred as a “D” sign [6,7]. Other
0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Secko M, et al, Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.06.037
2
M. Secko et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. A parasternal short-axis view of the heart. The pulmonary artery (PA) is outlined and lies adjacent to the aortic valve (AV). Arrow denotes echogenic thrombus overlying the bifurcation of the pulmonary artery.
ultrasound findings include right atrial or pulmonary artery dilation, right heart thrombus or thrombus in-transition, and moderate to severe tricuspid regurgitation on Doppler [6,7]. The diagnostic accuracy of RVD on TTE to diagnosis PE ranges and depends on sonographer experience. The reported sensitivity is 32% to 93% with specificity of 82% to 98% [4,8–12] for TTE to diagnose PE. In conclusion, point-of-care cardiac ultrasound (TTE) should be considered and used in all patients with diagnosed or suspected of having a PE, particularly a saddle embolus as the ultrasound will help determine the severity and ultimately guide further management of this disease process. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2016.06.037.
Michael Secko MD, RDMS⁎ Eric Legome MD Stephan Rinnert MD Department of Emergency Medicine SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203 ⁎ Corresponding author. Department of Emergency Medicine SUNY Downstate/Kings County Hospital Center, Brooklyn, NY 11203 Tel.: +1 631 645 7200; fax: +1 631 239 1754 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2016.06.037
References [1] Musani MH. Asymptomatic saddle pulmonary embolism: case report and literature review. Clin Appl Thromb Hemost 2011;17(4):337–9. [2] Ryu JH, Pellikka PA, Froehling DA, Peters SG, Aughenbaugh GL. Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome. Respir Med 2007;101(7):1537–42. [3] Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136(9):691–700. [4] Grifoni S, Olivotto I, Cecchini P, Pieralli F, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000;101(24):2817–22. [5] Torbicki A, Galie N, Covezzoli A, Rossi E, et al. Right heart thrombi in pulmonary embolism. Results from the international cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245–51. [6] Rudski LG, Lai WW, Afilalo J, Hua L, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685–713. [7] Rudoni RR, Jackson RE, Godfrey GW, Bonfiglio AX. Use of two-dimensional echocardiography for the diagnosis of pulmonary embolus. J Emerg Med 1998;16(1):5–8. [8] Dresden S, Mitchell P, Rahimi L, Leo M, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med 2014;63(1):16–24. [9] Perrier A, Tamm C, Unger PF, Lerch R, Sztajzel J. Diagnostic accuracy of Dopplerechocardiography in unselected patients with suspected pulmonary embolism. Int J Cardiol 1998;65(1):101–9. [10] Miniati M, Monti S, Pratali L, Di Ricco G, et al. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Am J Med 2001;110(7):528–35. [11] Nazeyrollas P, Metz D, Jolly D, Maillier B, et al. Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism. Eur Heart J 1996;17(5):779–86. [12] Nazerian P, Vanni S, Volpicelli G, Gigli C, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014;145(5): 950–7.
Fig. 2. Computed tomography angiogram of the chest at the level of the pulmonary bifurcation. Two arrows delineate the saddle embolus.
Please cite this article as: Secko M, et al, Saddle embolism diagnosed by point-of-care transthoracic echocardiography before computed tomography angiogram of the chest, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.06.037