Skip to main content
SpringerLink
Log in

Regional right ventricular dysfunction in acute pulmonary embolism: relationship with clot burden and biomarker profile

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Regional right ventricular (RV) dysfunction (RRVD) is an echocardiographic feature in acute pulmonary embolism (PE), primarily reported in patients with moderate-to-severe RV dysfunction. This study investigated the clinical importance of RRVD by assessing its relationship with clot burden and biomarkers. We identified consecutive patients admitted to the emergency department between 1999 and 2014 who underwent computed tomographic angiography, echocardiography, and biomarker testing (troponin and NT-proBNP) for suspected acute PE. RRVD was defined as normal excursion of the apex contrasting with hypokinesis of the mid-free wall segment. RV assessment included measurements of ventricular dimensions, fractional area change, free-wall longitudinal strain and tricuspid annular plane systolic excursion. Clot burden was assessed using the modified Miller score. Of 82 patients identified, 51 had acute PE (mean age 66 ± 17 years, 43 % male). No patient had RV myocardial infarction. RRVD was present in 41 % of PEs and absent in all patients without PE. Among patients with PE, 86 % of patients with RRVD had central or multi-lobar PE. Patients with RRVD had higher prevalence of moderate-to-severe RV dilation (81 vs. 30 %, p < 0.01) and dysfunction (86 vs. 23 %, p < 0.01). There was a strong trend for higher troponin level in PE patients with RRVD (38 vs. 13 % in PE patients without RRVD, p = 0.08), while there was no significant difference for NT-proBNP (67 vs. 73 %, p = 0.88). RRVD showed good concordance between readers (87 %). RRVD is associated with an increased clot burden in acute PE and is more prevalent among patients with moderate-to-severe RV enlargement and dysfunction.

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
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996) Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 78:469–473

    Article  CAS  PubMed  Google Scholar 

  2. Goldhaber SZ (1998) Pulmonary embolism. N Engl J Med 339:93–104

    Article  CAS  PubMed  Google Scholar 

  3. Sosland RP, Gupta K (2008) Images in cardiovascular medicine: McConnell’s Sign. Circulation 118:e517–e518

    Article  PubMed  Google Scholar 

  4. Torrent Guasp F (2001) Agonist-antagonist mechanics of the descendent and ascendent segments of the ventricular myocardial band. Rev Esp Cardiol 54:1091–1102

    Article  Google Scholar 

  5. Bankier AA, Janata K, Fleischmann D, Kreuzer S, Mallek R, Frossard M et al (1997) Severity assessment of acute pulmonary embolism with spiral CT: evaluation of two modified angiographic scores and comparison with clinical data. J Thorac Imaging 12:150–158

    Article  CAS  PubMed  Google Scholar 

  6. Voigt J-U, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R et al (2015) Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 16:1

    Article  CAS  PubMed  Google Scholar 

  7. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K 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

    Article  PubMed  Google Scholar 

  8. Geyer H, Caracciolo G, Abe H, Wilansky S, Carerj S, Gentile F et al (2010) Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr 23:351–369

    Article  PubMed  Google Scholar 

  9. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28:1–39

    Article  PubMed  Google Scholar 

  10. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N et al (2014) 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 35:3033–3069

    Article  PubMed  Google Scholar 

  11. Kurzyna M, Torbicki A, Pruszczyk P, Burakowska B, Fijałkowska A, Kober J et al (2002) Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol 90:507–511

    Article  PubMed  Google Scholar 

  12. Platz E, Hassanein AH, Shah A, Goldhaber SZ, Solomon SD (2012) Regional right ventricular strain pattern in patients with acute pulmonary embolism. Echocardiography 29:464–470

    Article  PubMed  Google Scholar 

  13. López-Candales A, Edelman K, Candales MD (2010) Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited. Echocardiography 27:614–620

    Article  PubMed  Google Scholar 

  14. Lodato JA, Ward RP, Lang R (2008) Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardiography 25:584–590

    Article  PubMed  Google Scholar 

  15. Vedovati M, Becattini C, Agnelli G, Kamphuisen P, Masotti L, Pruszczyk P et al (2012) Multidetector CT scan for acute pulmonary embolism: embolic burden and clinical outcome. Chest 142:1417–1424

    Article  PubMed  Google Scholar 

  16. Pruszczyk P, Kostrubiec M, Bochowicz A, Styczyński G, Szulc M, Kurzyna M et al (2003) N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J 22:649–653

    Article  CAS  PubMed  Google Scholar 

  17. Becattini C, Vedovati MC, Agnelli G (2007) Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 116:427–433

    Article  CAS  PubMed  Google Scholar 

  18. Kucher N, Goldhaber SZ (2003) Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation 108:2191–2194

    Article  PubMed  Google Scholar 

  19. Shah P, Schleifer JW, Mookadam F, Chandrasekaran K (2015) Right ventricular myocardial infarction: an underrecognized aetiology of McConnell’s sign. Eur Heart J Cardiovasc Imaging 16:225

    Article  PubMed  Google Scholar 

  20. Casazza F, Bongarzoni A, Capozi A, Agostoni O (2005) Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr 6:11–14

    Article  PubMed  Google Scholar 

  21. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

    Article  PubMed  Google Scholar 

  22. Raina A, Vaidya A, Gertz ZM, Chambers S, Forfia PR (2013) Marked changes in right ventricular contractile pattern after cardiothoracic surgery: implications for post-surgical assessment of right ventricular function. J Heart Lung Transplant 32:777–783

    Article  PubMed  Google Scholar 

  23. Sugiura E, Dohi K, Onishi K, Takamura T, Tsuji A, Ota S et al (2009) Reversible right ventricular regional non-uniformity quantified by speckle-tracking strain imaging in patients with acute pulmonary thromboembolism. J Am Soc Echocardiogr 22:1353–1359

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

M.A. received a research fellowship from the Fédération Française de Cardiologie. M.V.M. receives MRI research support from GE Healthcare. None of the other authors have any conflicts of interest relative to the study.

Author information

Author notes

    Authors and Affiliations

    1. Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA

      Mirela Tuzovic, Sasikanth Adigopula, Myriam Amsallem, Yukari Kobayashi, David Liang, Ingela Schnittger, Michael V. McConnell & François Haddad

    2. Unité de Recherche Clinique, Marie Lannelongue Hospital, University of Paris XI, Le Plessis Robinson, France

      David Boulate

    3. Division of Radiology, Stanford University School of Medicine, Stanford, CA, USA

      Michael Kadoch & Dominik Fleischmann

    4. Center for Clinical Informatics, Stanford University Medical Center, Palo Alto, CA, USA

      Gomathi Krishnan

    5. Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA

      Mirela Tuzovic, Sasikanth Adigopula, Myriam Amsallem, Yukari Kobayashi, David Liang, Ingela Schnittger, Michael V. McConnell & François Haddad

    Authors
    1. Mirela Tuzovic
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Sasikanth Adigopula
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Myriam Amsallem
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Yukari Kobayashi
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Michael Kadoch
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. David Boulate
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Gomathi Krishnan
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. David Liang
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Ingela Schnittger
      View author publications

      You can also search for this author in PubMed Google Scholar

    10. Dominik Fleischmann
      View author publications

      You can also search for this author in PubMed Google Scholar

    11. Michael V. McConnell
      View author publications

      You can also search for this author in PubMed Google Scholar

    12. François Haddad
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Myriam Amsallem.

    Ethics declarations

    This research involves human participants. All participants gave their informed consent before inclusion.

    Conflict of interest

    None of the authors have any conflicts of interest.

    Additional information

    Mirela Tuzovic, Sasikanth Adigopula and Myriam Amsallem have contributed equally to this study.

    Electronic supplementary material

    Below is the link to the electronic supplementary material.

    Figure S1:

    Inter-observer agreement of the regional RV dysfunction between level 3 and level 2 readers. (+): Regional RV dysfunction (RRVD) classified as present/(−): RRVD classified as absent. L2 represents level 2 reader and L3 level 3. (TIFF 968 kb)

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Tuzovic, M., Adigopula, S., Amsallem, M. et al. Regional right ventricular dysfunction in acute pulmonary embolism: relationship with clot burden and biomarker profile. Int J Cardiovasc Imaging 32, 389–398 (2016). https://doi.org/10.1007/s10554-015-0780-1

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s10554-015-0780-1

    Keywords

    Search

    Navigation