Original article
Natural History of Right Ventricular Dysfunction After Acute Pulmonary Embolism

https://doi.org/10.1016/j.echo.2006.12.005Get rights and content

Background

Acute pulmonary embolism (PE) associated with right ventricular (RV) dysfunction has an adverse prognosis. We investigated individual parameters of RV dysfunction after acute PE, assessing their correlation with the PE extent and recovery during 6 months.

Methods

In all, 35 patients (age 63 ± 18 years) with acute PE were prospectively investigated for 6 months with serial echocardiography, incorporating longitudinal myocardial-velocity and strain imaging. The extent of PE was quantified on day 1 by ventilation/perfusion pulmonary scintigraphy with PE defined as large when there was greater than 30% lung involvement.

Results

PE extent correlated strongly with a number of parameters of RV function, and the strongest univariate correlates were tricuspid annular motion (TAM) (r = −0.65, P < .0001) and the ratio of RV apical to RV basal systolic velocity (r = 0.66, P < .0001). Multivariate analysis identified TAM (P < .0001) and RV basal late-diastolic velocity (P = .01) as independently predicting PE extent, with a combined correlation (R2 = 0.52, P < .0001). A TAM of less than 2.0 cm had sensitivity, specificity, and positive- and negative-predictive values of 75%, 84%, 75%, and 79%, respectively, in predicting large PE. Prospective follow-up identified that RV:left ventricular end-diastolic area ratio returned to normal within 6 weeks, whereas TAM and ratio of RV apical to RV basal systolic velocity normalized after 3 to 6 months.

Conclusion

TAM and ratio of RV apical to RV basal systolic velocity are useful indicators of the extent of PE, and provide unique insights into the recovery of RV function after acute PE.

Section snippets

Methods

From 2004 to 2006, consecutive adult patients in the emergency department of a tertiary referral hospital presenting with a clinical history of suspected acute PE and ventilation/perfusion pulmonary scintigraphy demonstrating high probability for PE who agreed to regular investigations for 6 months were included in the study (n = 35; 18 of 35 male; 17 of 35 had large PE ≥ 30% lung volume, 9 of 35 had massive PE ≥ 50% lung volume). The study was approved by our human ethics committee. Written

Results

The patient characteristics are summarized in Table 1. The day-1 D-dimer (2.2 ± 3.2, normal < 0.25 mg/L), BNP (130 ± 222, normal < 100 pg/mL), troponin-T (0.02 ± 0.02, normal < 0.01 μg/L), and DLCO (69 ± 15% of reference value) were abnormal compared with reference standards. Four patients (11%) had bleeding complications, however, none required blood transfusion. One patient developed intracranial hemorrhage while on oral anticoagulation. There were no in-hospital deaths. Two patients died

Discussion

The identification of robust and reproducible parameters of RV function has the potential to substantially improve the treatment of patients with acute PE. We report for the first time that TAM and RV basal Am are strongly predictive of PE size, and that whereas RV dilatation improves during 6 weeks, subclinical RV systolic dysfunction persists beyond 3 months.

Our results indicate that TAM (P = .0001) is the strongest independent echocardiographic marker of embolic load in acute PE, and

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