Pulmonary Embolism Diagnosed From Right Heart Changes Seen After Exercise Stress Echocardiography

Abstract

A 47-year-old black woman with no prior medical problems presented to the emergency department after a syncopal event associated with palpitations while walking. The patient noticed new onset of palpitations while walking that lasted about an hour. She subsequently had a syncopal episode. She denied dizziness, lightheadedness, dehydration, or seizure-like activity. Medications included antihistamines and oral contraceptives. On admission she was afebrile, heart rate 84 bpm, blood pressure 121/73 mm Hg, respiratory rate 18 breaths per minute, and her oxygen saturation was 97% on room air. The physical examination was normal except for a small (1 cm) head laceration.A noncontrast computed tomography of the head was negative for any acute intracranial findings. The chest radiograph showed no acute cardiopulmonary disease. The electrocardiogram showed normal sinus rhythm at a ventricular rate of 69 bpm, no evidence of ST segment changes, and an isolated T wave inversion in V2 (Figure 1).She was admitted with high suspicion for cardiac syncope given her symptoms of palpitations before the event. Myocardial infarction was ruled out. A pro-B-type natriuretic peptide was normal and thyroid-stimulating hormone test was normal. A D-dimer level was not checked. Telemetry was only significant for episodes of sinus tachycardia. A resting transthoracic echocardiogram was technically difficult but showed normal left ventricular (LV) size and function, ejection fraction 50%, and grossly normal right ventricular (RV) size and function (Figure 2; Movies I and II in the Data Supplement). There was not enough tricuspid regurgitation on the resting echocardiogram for estimation of pulmonary artery systolic pressure at rest.The clinical team ordered a stress echocardiogram which was performed for evaluation of ischemia and arrhythmia. The test was terminated at 3 minutes and 53 seconds, after the patient exhibited symptoms of dyspnea and fatigue. The electrocardigram was positive for exercise-induced myocardial ischemia (>2 mm ST segment depression in the inferior and lateral leads) at maximal stress of 103% maximum predicted heart rate and 5 metabolic equivalents (Figure 3). There was blunted blood pressure response to exercise from 110/68 mm Hg at baseline to 118/62 mm Hg at peak stress. After stress echocardiographic imaging, using perflutren contrast for improved endocardial border visualization demonstrated normal augmentation of LV function. However, there was significant dilation of the RV, with severe RV dysfunction and flattening of the interventricular septum, suggestive of RV pressure and volume overload (Figure 4; Movies I and II in the Data Supplement). There was an insufficient degree of tricuspid regurgitation to allow for estimation of RV systolic pressures. This information suggested an abnormality in the pulmonary vascular physiology, likely because of increased pulmonary vascular resistance and inadequate contractile reserve of the RV. In our clinical scenario, these findings were considered suspicious for an acute...

Exercise Echocardiography Findings and Outcome in Patients with Right Ventricular Dilation not Related to Left-Sided Heart Disease

“…In four of them (19%) RV dysfunction, septal shift, or pulmonary hypertension developed exclusively at exercise. Previous isolated case-report studies have shown RV dilation and pulmonary hypertension detected exclusively at exercise in patients with PTE [9,10]. The advantage of suspecting PTE lies on specific treatment available for it [1].…”

Presentación atípica de tromboembolismo pulmonar detectado mediante ecocardiografía de estrés

“…Con respecto al diagnóstico mediante ecocardiografía de estrés de un TEP agudo son muy escasos los reportes publicados en la literatura 2,3 . En ambos el ecocardiograma basal era normal y con el esfuerzo desarrollaron datos de dilatación y sobrecarga de cavidades derechas, confirmando a posteriori el diagnóstico de TEP mediante angioTAC de arterias pulmonares, similar a lo acontecido en nuestro caso 2,3 .…”