The early echocardiographic diagnosis of a massive pulmonary embolism

BACKGROUND: In several cases of clinically suspected massive pulmonary embolism (MPE), a lung perfusion scanning and/or a pulmonary angiography are not quickly available or feasible. METHODS: Fifty patients admitted to our ICU with a clinically suspected MPE underwent an echocardiographic (Echo) investigation very shortly after onset (within 2 hours in 38 cases, and within 6 hours in 12). An Echo-Doppler study was also performed in 18 patients. RESULTS: Highly significant differences (p < 0.001) emerged between patients with PE and healthy age-mates for each type of Echo measurement and in all views. The RVDD/LVDD ratio turned out to be the most frequently affected parameter, being altered in 96% of cases. An abnormal diastolic leftward shift of the interventricular septum was detected in 81% of cases. Only one of our 50 patients failed to show any evidence of RV pressure overload; however, this was a patient with a severe dilated cardiomyopathy. In 22 cases in whom hemodynamic monitoring was performed, no significant correlation emerged between RVDD and LVDD, on one hand, mean PAP and cardiac index on the other. All 18 patients examined by Echo-Doppler had mild to moderate tricuspid regurgitation with a peak RV-RA gradient of 38 +/- 7 mm Hg (range 31-53 mm Hg). Seven patients (14%) were found to harbor right heart thrombi when first examined. Overall mortality in this uncommonly high risk population was as high as 28%. CONCLUSIONS: In a clinical setting suggesting a MPE, an Echo study conducted very shortly after onset may corroborate a tentative diagnosis of PE, thereby permitting timely fibrinolytic therapy pending a lung scan and/or angiography, or in situations where such imaging facilities are not available or readily usable.