McConnell's sign: Echocardiography in the management of acute pulmonary embolism
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ABSTRACT:
SUBMITTER: Patel V
PROVIDER: S-EPMC8552222 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:A 48-year-old female was admitted after experiencing a brief syncopal episode. Three weeks ago the patient sustained a right arm humerus bone fracture in a motor vehicle accident. Since the accident, her mobility has been limited. CT angiogram of the chest revealed massive bilateral pulmonary emboli. A 2D echocardiogram was performed, which demonstrated McConnell sign and severe right ventricle dysfunction. Considering potential of hemodynamic instability, the patient received fibrinolytic therapy with Alteplase. A subsequent 2D echocardiogram showed complete resolution of McConnell sign and right ventricle dysfunction.
| S-EPMC4008391 | biostudies-literature
Project description:BACKGROUND:Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent. METHODS:Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested. RESULTS:Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants. CONCLUSION:The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.
| S-EPMC3913120 | biostudies-literature
Project description:BackgroundThree-dimensional intracardiac echocardiography (3D ICE) with wide azimuthal elevation is a novel technique performed for assessment of cardiac anatomy and guidance of intracardiac procedures, being able to provide unique views with good spatial and temporal resolution. Complications arising from this invasive procedure and the value of 3D ICE in the detection and diagnosis of acute cardiovascular pathology are not comprehensively described. This case illustrates a previously unreported iatrogenic complication of clot displacement from the intra-vascular sheath upon insertion of a 3D ICE catheter and the value of 3D ICE in immediate diagnosis of clot in transit through the heart with pulmonary embolism.Case presentationWe conducted a translational study of 3D ICE with wide azimuthal elevation to guide implantation of a left ventricular assist device (Impella CP®) in eight adult sheep. A large-bore 14 Fr central venous sheath was used to enable right atrial and right ventricular access for the intracardiac catheter. Insertion of the 3D ICE catheter was accompanied by a sudden severe cardiorespiratory deterioration in one animal. 3D ICE revealed a large highly mobile mass within the right heart chambers, determined to be a clot-in-transit. The diagnosis of pulmonary clot embolism resulting from the retrograde blood entry into the large-bore sheath introducer, rapid clot formation and consequent displacement into venous circulation by the ICE catheter was made. The sheep survived this life-threatening event following institution of cardiovascular support allowing completion of the primary research protocol.ConclusionThis report serves as a serious warning to the researchers and clinicians utilizing long large-bore sheath introducers for 3D ICE and illustrates the value of 3D ICE in detecting clot-in-transit within right heart chambers.
| S-EPMC7441699 | biostudies-literature
Project description:Highlights•McConnell's sign is not always demonstrated during a massive PE.•The pattern seen on echocardiography is another manifestation of right heart strain.•TAPSE and S? were unable to assess systolic function of the right ventricle.•Similarities arise between this case and takotsubo syndrome of the right ventricle.
| S-EPMC6302120 | biostudies-other
Project description:Perioperative pulmonary embolism can go undetected until the sudden onset of cardiopulmonary collapse. Point of care echocardiography in such setting can narrow the differential diagnosis of precipitous instability and facilitate tailored, rather than empiric, therapy in the event of a massive pulmonary embolism. We describe the diagnosis and successful multidisciplinary management of intraoperative massive pulmonary embolism aided by both transthoracic and transesophageal echocardiography. Key aspects regarding the classification and treatment of pulmonary embolism are subsequently reviewed.
| S-EPMC5857334 | biostudies-literature
Project description:Pulmonary embolism (PE) is a devastating diagnosis which carries a high mortality risk. Echocardiography is often performed to risk stratify patients diagnosed with PE, and guide management strategies. Trends in the performance of echocardiography among patients with PE and its role in influencing outcomes is unknown.We analyzed the 2005 to 2014 National Inpatient Sample Database to identify patients with primary diagnosis of PE or secondary diagnosis of PE and ?1 of the following diagnoses: syncope, thrombolysis, acute deep vein thrombosis, acute cardiorespiratory failure, and secondary pulmonary hypertension. Trends in the performance of echocardiography and in-hospital mortality were analyzed. The admissions were divided into 2 groups with echocardiography, and without echocardiography, and 1:2 propensity score matching (PSM) was performed for comparison. The primary end-point was in-hospital mortality. The secondary endpoints were length of stay and total hospitalization costs. Odd ratios (OR) with confidence intervals (CI) were reported.A total of 299,536 unweighted PE cases were studied. Performance of echocardiography among patients with PE patients increased from 3.5% to 5.6%, whereas in-hospital mortality decreased from 4.2% to 3.7% between years 2005 and 2014. Before matching, patients who received an echocardiogram were more likely to be younger, African American, admitted to a large, urban teaching institute, and had higher rates of concurrent acute deep vein thrombosis, and acute respiratory failure. Post-PSM, patients who received echocardiography during hospitalization had lower in-hospital mortality (odds ratio 0.75, 95% confidence intervals (CI) 0.68-0.83; P?<?0.001), longer length of stay (median 6 days vs 5 days; P?<?.001) and higher mean hospitalization costs ($34,379 vs $27,803; P?<?.001) compared to those without echocardiography.Performance of echocardiography among patients with a PE is increasing and is associated with lower in-hospital mortality.
| S-EPMC6392756 | biostudies-literature
Project description:BackgroundWe determine the predictive value of transthoracic echocardiographic (TTE) metrics for clinical deterioration within 5 days in adults with intermediate-risk pulmonary embolism (PE).MethodsThis was a prospective observational study of intermediate-risk PE patients. To determine associations of TTE and clinical predictors with clinical deterioration, we used univariable analysis, Youden's index for optimal thresholds, and multivariable analyses to report odds ratios (ORs) or area under the curve (AUC).ResultsOf 306 intermediate-risk PE patients, 115 (37.6%) experienced clinical deterioration. PE patients who had clinical deterioration within 5 days had greater baseline right ventricle (RV) dilatation and worse systolic function than the group without clinical deterioration as indicated by the following: RV basal diameter 4.46 ± 0.77 versus 4.20 ± 0.77 cm; RV/LV basal width ratio 1.14 ± 0.29 versus 1.02 ± 0.24; tricuspid annular plane systolic excursion (TAPSE) 1.56 ± 0.55 versus 1.80 ± 0.52 cm; and RV systolic excursion velocity 10.40 ± 3.58 versus 12.1 ± 12.5 cm/s, respectively. Optimal thresholds for predicting clinical deterioration were: RV basal width 3.9 cm (OR 2.85 [1.64, 4.97]), RV-to-left ventricle (RV/LV) ratio 1.08 (OR 3.32 [2.07, 5.33]), TAPSE 1.98 cm (OR 3.3 [2.06, 5.3]), systolic excursion velocity 10.10 cm/s (OR 2.85 [1.75, 4.63]), and natriuretic peptide 190 pg/mL (OR 2.89 [1.81, 4.62]). Significant independent predictors were: transient hypotension 6.1 (2.2, 18.9), highest heart rate 1.02 (1.00, 1.03), highest respiratory rate 1.02 (1.00, 1.04), and RV/LV ratio 1.29 (1.14, 1.47). By logistic regression and random forest analyses, AUCs were 0.80 (0.73, 0.87) and 0.78 (0.70, 0.85), respectively.ConclusionsBasal RV, RV/LV ratio, and RV systolic function measurements were significantly different between intermediate-risk PE patients grouped by subsequent clinical deterioration.
| S-EPMC9166499 | biostudies-literature
Project description:IntroductionAcute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients.Purpose of reviewThe purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic.Recent findingsThere are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging.SummaryCurrent use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.
| S-EPMC8113788 | biostudies-literature
Project description:Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.
| S-EPMC4222429 | biostudies-literature
Project description:Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
| S-EPMC9409943 | biostudies-literature