Analysis of the 60/60 Sign and Other Right Ventricular Parameters by 2D Transthoracic Echocardiography as Adjuncts to Diagnosis of Acute Pulmonary Embolism

Abstract

The 60/60 sign in 2D transthoracic echocardiography (TTE)-a combination of pulmonary acceleration time (PAT) less than 60 milliseconds and tricuspid regurgitation (TR) jet gradient of less than 60 mmHg-has been found to be specific for the diagnosis of pulmonary embolism (PE). Materials and methods An observational prospective analysis was carried out on cases of suspected PE presenting to the emergency room (ER). TTE was performed on all cases with suspected PE prior to computed tomography pulmonary angiography (CTPA). Emphasis was placed on measurement of PAT and early systolic notching (ESN) on the pulsed wave (PW) Doppler of the pulmonary valve, TR jet gradient, right ventricle systolic excursion velocity (RV S') by tissue doppler imaging (TDI), tricuspid annular plane systolic excursion (TAPSE), and right ventricle to left ventricle end-diastolic dimension ratio (RV:LV EDD) in modified parasternal short-axis view. These signs were taken as screening tests and compared to CTPA as the standard test. Patients were followed up until hospital discharge or death. Observations Fifty-six cases of suspected PE were enrolled for the study. Of these, 24 cases of PE were confirmed by CTPA. Out of 24 cases of PE, 15 were high-risk PE, six were intermediate high-risk PE, and three were intermediate low-risk PE. The mean age was 53.07±9.79 years with a male-to-female ratio of 1.95:1. The 60/60 sign was present in 70.83% of cases of PE. RV:LV EDD in a modified short-axis view of more than 0.9 was present in 91.67% of cases of PE, and ESN on the PW Doppler of the pulmonary valve was present in 75% of cases of PE. The 60/60 sign, RV:LV EDD ratio more than 0.9, and ESN showed sensitivities of 70.83%, 91.67%, 75%, and specificities of 93.75%, 75%, and 100%, respectively for PE. For prediction of mortality, presence of the 60/60 sign (Odds Ratio=8.13, p-value=0.034) and ESN (Odds Ratio=17.50, p-value=0.02) were statistically significant. Conclusions 60/60 sign and ESN are specific for the diagnosis of PE but have poor sensitivity.

Comparison of echocardiographic pulmonary flow Doppler markers in patients with massive or submassive acute pulmonary embolism and control group: A cross‐sectional study

“…They suggested that ESN and 60/60 signs have excellent specificity while moderate sensitivity for diagnosing PE. 20 Lodato et al demonstrated that the right ventricle to left ventricle end‐diastolic dimension ratio > 0.7 accurately predicts PE with a sensitivity of 66% and specificity of 77%. In addition, MC sign had high specificity (96%) while low sensitivity (16%) for the diagnosis of PE.…”

“…In addition, the ESN, 60/60 sign, and right ventricle to left ventricle end‐diastolic dimension ratio>0.9 had sensitivities of 75%, 70.83%, and 91.67%, and specificities of 100%, 93.75%, and 75%, respectively. They suggested that ESN and 60/60 signs have excellent specificity while moderate sensitivity for diagnosing PE 20 . Lodato et al demonstrated that the right ventricle to left ventricle end‐diastolic dimension ratio > 0.7 accurately predicts PE with a sensitivity of 66% and specificity of 77%.…”

“…They suggested that ESN and 60/60 signs have excellent specificity while moderate sensitivity for diagnosing PE 20. Lodato et al11 Based on the findings of other studies, such as the article by Afonso et al, the statement that no finding was seen in 70% of patients is doubtful 12.…”

Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK): A novel independent predictor of 30-day mortality in patients with acute pulmonary embolism

“…Act <81 ms was associated with 30-day mortality in a prospective blinded study [23]. The 60/60 sign was shown to be a good predictor of in-hospital mortality in PE patients (odds ratio [OR], 6.13; 95% CI, 1.11-59.21; P = 0.03) [24]. In the analysis of the echocardiographic pattern of 511 consecutive patients with acute PE, the coexistence of the 60/60 sign with the McConnell sign and an enlarged hypokinetic RV was recognized as the most useful echocardiographic criterion for RV dysfunction [25].…”

The 2023 Core Content of advanced emergency medicine ultrasonography

“…Lahham et al72 found that TAPSE measurements less than 15.2 mm exhibited high specificity in identifying clinically significant acute pulmonary embolism. POCUS also enables the assessment of right ventricular outflow tract velocity and pulmonary artery systolic pressure, which are valuable in evaluating conditions like pulmonary embolism and assessing the hemodynamic impact of right ventricular dysfunction 57. Prior studies have demonstrated the accuracy and clinical relevance of focused cardiac ultrasound in evaluating diastolic function parameters such as mitral inflow velocities (E and A waves), deceleration time,…”