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

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.

Right Heart End-Systolic Remodeling Index Strongly Predicts Outcomes in Pulmonary Arterial Hypertension

“…In our laboratory, we have found this to be more reproducible as we use careful landmarks and we have previously shown the excellent reliability of manual derived strain values in the left heart. 29,30 The validation of the normative values of RV strain in our healthy cohort and the validation of the thresholds described by Fine et al both support the validity of our method. 7,12 …”

Echocardiography in the Risk Assessment of Acute Pulmonary Embolism

“…24 McConnell sign is a relatively specific sign for acute PE, although it has low sensitivity (ranging from 40 to 60% in studies). 22,25,26 Notably, although apical function appears to be preserved in a McConnell sign, global and segmental RV strains are lower in it compared with normal controls. 22…”

Right heart imaging in patients with heart failure

“…A specific MRI pattern, described as a focal “crinkling” of the RV outflow tract and subtricuspid regions (accordion sign), has been reported as a promising sign for early diagnosis of ARVC/D as only found in mutation carrier (53). The accordion sign is an example of regional RV wall motion abnormalities, similar to the regional contraction abnormalities first described by McConnell et al two decades ago (54) in patients with acute pulmonary embolism, and recently revisited using echocardiographic strain (55). …”