Skip to main content
SpringerLink
Log in

Low concordance between CTPA and echocardiography in identification of right ventricular strain in PERT patients with acute pulmonary embolism

  • Original Article
  • Published:
Emergency Radiology Aims and scope Submit manuscript

Abstract

Purpose

Right ventricular strain (RVS) is used to risk stratify patients with acute pulmonary embolism (PE) and influence treatment decisions. Guidelines suggest that either computed tomography pulmonary angiography (CTPA) or transthoracic echocardiography (TTE) can be used to assess RVS. We sought to determine how often CTPA and TTE yield discordant results and to assess the test characteristics of CTPA compared to TTE.

Methods

We analyzed data from a single-center registry of PE cases severe enough to warrant activation of the hospital’s Pulmonary Embolism Response Team (PERT). We defined RVS as a right ventricular to left ventricular ratio (RV/LV) ≥ 1 or radiologist’s interpretation of RVS on CTPA or as the presence of either RV dilation, hypokinesis, or septal bowing on TTE.

Results

We included 554 patients in our analysis, of whom 333 (60%) had concordant RVS findings on CTPA and TTE. Using TTE as the reference standard, CTPA had a sensitivity of 95% (95% CI 92–97%) and a specificity of 4% (95% CI 2–8%) for identifying RVS.

Conclusions

In a selected population of patients with acute PE for which PERT was activated, CTPA is highly sensitive but not specific for the detection of RVS when compared to TTE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data Availability

Data is available upon reasonable request.

References

  1. Konstantinides SV, Meyer G, Becattini C et al (2020) 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 41:543–603. https://doi.org/10.1093/eurheartj/ehz405

    Article  PubMed  Google Scholar 

  2. Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A (2020) Pulmonary vasodilation in acute pulmonary embolism – a systematic review. Pulm Circ 10:2045894019899775. https://doi.org/10.1177/2045894019899775

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Matthews JC, McLaughlin V (2008) Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 4:49–59. https://doi.org/10.2174/157340308783565384

    Article  PubMed  PubMed Central  Google Scholar 

  4. Brailovsky Y, Allen S, Masic D et al (2021) Risk stratification of acute pulmonary embolism. Curr Treat Options Cardiovasc Med 23:48. https://doi.org/10.1007/s11936-021-00923-4

    Article  Google Scholar 

  5. Rudski LG, Lai WW, Afilalo J et al (2010) Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685–713. https://doi.org/10.1016/j.echo.2010.05.010. (quiz 786–8)

    Article  PubMed  Google Scholar 

  6. Bova C, Greco F, Misuraca G et al (2003) Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med 21:180–183. https://doi.org/10.1016/s0735-6757(02)42257-7

    Article  PubMed  Google Scholar 

  7. Jones AE, Kline JA (2003) Availability of technology to evaluate for pulmonary embolism in academic emergency departments in the United States. J Thromb Haemost 1:2240–2242. https://doi.org/10.1046/j.1538-7836.2003.00370.x

    Article  CAS  PubMed  Google Scholar 

  8. Goldhaber SZ (2002) Echocardiography in the management of pulmonary embolism. Ann Intern Med 136:691. https://doi.org/10.7326/0003-4819-136-9-200205070-00012

    Article  PubMed  Google Scholar 

  9. Zhang LJ, Lu GM, Meinel FG et al (2015) Computed tomography of acute pulmonary embolism: state-of-the-art. Eur Radiol 25:2547–2557. https://doi.org/10.1007/s00330-015-3679-2

    Article  PubMed  Google Scholar 

  10. Trujillo-Santos J, den Exter PL, Gómez V et al (2013) Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis. J Thromb Haemost 11:1823–1832. https://doi.org/10.1111/jth.12393

    Article  CAS  PubMed  Google Scholar 

  11. Dudzinski DM, Hariharan P, Parry BA et al (2017) Assessment of right ventricular strain by computed tomography versus echocardiography in acute pulmonary embolism. Acad Emerg Med 24:337–343. https://doi.org/10.1111/acem.13108

    Article  PubMed  Google Scholar 

  12. Bossuyt PM, Reitsma JB, Bruns DE et al (2015) STARD 2015: An updated list of essential items for reporting diagnostic accuracy studies. Radiology 277:826–832. https://doi.org/10.1148/radiol.2015151516

    Article  PubMed  Google Scholar 

  13. Prosperi-Porta G, Ronksley P, Kiamanesh O et al (2022) Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis. Eur Respir Rev 31:220120. https://doi.org/10.1183/16000617.0120-2022

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kabrhel C, Okechukwu I, Hariharan P et al (2014) Factors associated with clinical deterioration shortly after PE. Thorax 69:835–842. https://doi.org/10.1136/thoraxjnl-2013-204762

    Article  PubMed  Google Scholar 

  15. Barco S, Mahmoudpour SH, Planquette B et al (2019) Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 40:902–910. https://doi.org/10.1093/eurheartj/ehy873

    Article  PubMed  Google Scholar 

  16. Lyhne MD, Schultz JG, MacMahon PJ et al (2019) Septal bowing and pulmonary artery diameter on computed tomography pulmonary angiography are associated with short-term outcomes in patients with acute pulmonary embolism. Emerg Radiol 26:623–630. https://doi.org/10.1007/s10140-019-01709-9

    Article  PubMed  Google Scholar 

  17. Meinel FG, Nance JW, Schoepf UJ et al (2015) Predictive value of computed tomography in acute pulmonary embolism: systematic review and meta-analysis. Am J Med 128:747–59.e2. https://doi.org/10.1016/j.amjmed.2015.01.023

    Article  PubMed  Google Scholar 

  18. Barrios D, Morillo R, Lobo JL et al (2017) Assessment of right ventricular function in acute pulmonary embolism. Am Heart J 185:123–129. https://doi.org/10.1016/j.ahj.2016.12.009

    Article  PubMed  Google Scholar 

  19. Kabrhel C, Rosovsky R, Channick R et al (2016) A multidisciplinary pulmonary embolism response team initial 30-month experience with a novel approach to delivery of care to patients with submassive and massive pulmonary embolism. Chest 150:384–393. https://doi.org/10.1016/j.chest.2016.03.011

    Article  PubMed  Google Scholar 

  20. Attia NM, Seifeldein GS, Hasan AA, Hasan A (2015) Evaluation of acute pulmonary embolism by sixty-four slice multidetector CT angiography: correlation between obstruction index, right ventricular dysfunction and clinical presentation. Egypt J Radiol Nucl Med 46:25–32. https://doi.org/10.1016/j.ejrnm.2014.10.007

    Article  Google Scholar 

  21. Henzler T, Krissak R, Reichert M et al (2010) Volumetric analysis of pulmonary CTA for the assessment of right ventricular dysfunction in patients with acute pulmonary embolism. Acad Radiol 17:309–315. https://doi.org/10.1016/j.acra.2009.10.022

    Article  PubMed  Google Scholar 

  22. Ozsu S, Karaman K, Mentese A et al (2010) Combined risk stratification with computerized tomography/echocardiography and biomarkers in patients with normotensive pulmonary embolism. Thromb Res 126:486–492. https://doi.org/10.1016/j.thromres.2010.08.021

    Article  CAS  PubMed  Google Scholar 

  23. Gutte H, Mortensen J, Mørk ML et al (2017) Non-ECG-gated CT pulmonary angiography and the prediction of right ventricular dysfunction in patients suspected of pulmonary embolism. Clin Physiol Funct Imaging 37:575–581. https://doi.org/10.1111/cpf.12325

    Article  CAS  PubMed  Google Scholar 

  24. Thakur R, Singhal M, Aggrawal AN et al (2022) Comparison of high-pitch prospective electrocardiogram-gated pulmonary CT angiography with standard CT pulmonary angiography on dual-source CT for detection of subsegmental pulmonary embolism in patients suspected of acute pulmonary embolism. Pol J Radiol 87:e296–e303. https://doi.org/10.5114/pjr.2022.117065

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA

    Mads Dam Lyhne, Nicholas Giordano, Jasmine Torrey, Grace Wang, Blair Alden Parry & Christopher Kabrhel

  2. Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark & Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

    Mads Dam Lyhne

  3. Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA

    David Dudzinski

  4. Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA

    Hui Zheng

  5. Department of Radiology, Massachusetts General Hospital, Boston, MA, USA

    Mannudeep K. Kalra

Authors
  1. Mads Dam Lyhne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nicholas Giordano
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David Dudzinski
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jasmine Torrey
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Grace Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hui Zheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Blair Alden Parry
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mannudeep K. Kalra
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Christopher Kabrhel
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Authors Mads Dam Lyhne, Nick Giordano, David Dudzinski, and Christopher Kabrhel contributed to study conception and design. Data collection and analysis were performed by Nick Giordano, Blair Alden Parry, Jasmine Torey, Grace Wang, and Hui Zheng. All authors contributed to interpretation of data. The first draft of the manuscript was written by Mads Dam Lyhne and Nick Giordano. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Christopher Kabrhel.

Ethics declarations

Ethics approval

Ethical approval was waived by the Mass General Brigham (MGB) Institutional Review Board (previously known as Partners Human Research Committee, protocol # 2016P000179) in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lyhne, M.D., Giordano, N., Dudzinski, D. et al. Low concordance between CTPA and echocardiography in identification of right ventricular strain in PERT patients with acute pulmonary embolism. Emerg Radiol 30, 325–331 (2023). https://doi.org/10.1007/s10140-023-02130-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10140-023-02130-z

Keywords

Search

Navigation