J Cardiovasc Ultrasound.  2011 Dec;19(4):224-227. 10.4250/jcu.2011.19.4.224.

Importance of Clinical and Echocardiographic Hemodynamic Assessment in Chronic Pulmonary Embolism

• Choe WS
• Kang DY
• Yoon JH
• Lee MH
• Cha MJ
• Kim HK
• Kim YJ
• Cho GY
• Sohn DW

• KMID: 1980389
• DOI: http://doi.org/10.4250/jcu.2011.19.4.224

Abstract

We describe a 42-year-old man presenting to the emergency department with cardiogenic shock. He had a prior history of acute pulmonary embolism (PE), and had been on anticoagulation for 2 years. Although computed tomographic pulmonary angiography performed at the emergency department showed no change in the extent of PE and did not support a role of surgical treatment, pulmonary embolectomy was recommended by attending physician based on clinical and echocardiographic hemodynamic findings like unstable vital sign and markedly enlarged right ventricle with severely depressed systolic function. Surgery confirmed the presence of fresh thrombi. After surgery, hemodynamic status was progressively improved, but the patient died due to pneumonia and pulmonary hemorrhage.

Keyword

Pulmonary embolism; Computed tomography; Echocardiography

MeSH Terms

Adult
Angiography
Echocardiography
Embolectomy
Emergencies
Heart Ventricles
Hemodynamics
Hemorrhage
Humans
Pneumonia
Pulmonary Embolism
Shock, Cardiogenic
Vital Signs

Figure

• 

  Fig. 1 A: Baseline computed tomographic pulmonary angiography (CTPA) performed 7 weeks before the index visit to emergency department (ED). Transverse sections show chronic pulmonary embolism (PE) with eccentric filling defects (white arrows) in the right descending pulmonary artery and segmental artery of the right lower lobe. Multiple focal filling defects (arrowheads) are also seen in subsegmental arteries of the right lower and left lower lobes. B: CTPA performed immediately after the ED visit. No definite interval change is seen in the extent of pre-existing chronic PE.

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  Fig. 2 A: Modified apical four-chamber view of the transthoracic echocardiography shows an enlarged right ventricular (RV) cavity with depressed RV systolic function. B: Parasternal short-axis view demonstrates an enlarged RV with flattening of the interventricular septum deviated to the left ventricle (white arrows). C: Tricuspid regurgitant jet with a maximum velocity of 3.58 m/sec. RA pressure was assumed to be 20 mmHg based on inferior vena cava response to respiration, resulting in an estimated pulmonary arterial systolic pressure of 71 mm Hg. D: Follow-up echocardiography performed on the 6th postoperative day shows improved RV systolic function and (E) improved degree of interventricular septal flattening (arrow).

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  Fig. 3 Surgical specimen of pulmonary embolectomy. Whitish-yellow organized thromboemboli with fresh red thrombi are clearly shown. RPA: right pulmonary artery, RUL: right upper lobe, RML: right middle lobe, RLL: right lower lobe, LPA: left pulmonary artery, LUL: left upper lobe, LLL: left lower lobe.

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