PULMONARY EMBOLISM ULTRASOUND DIAGNOSIS Asso/Pr Nguyen Van Tri University of medicine and pharmacy Ho chi minh city Case • A 65 year-old female in emergency department after collapsing in a shopping centre • Little other history, except information she had been on a trip to US recently • Quick bedside echo while the paramedics are changing over their monitoring Heart Ultrasound What are the obvious abnormalities on this echo? • Small LV cavity size with normal LV systolic function • Septal flattening consistent with RV pressure overload • Severely dilated RV with severely reduced systolic function Q2 What is McConnell’s sign? • Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex • 77% sensitivity and 94% specificity for diagnosis of pulmonary embolism Q3 What are the echocardiographic features of right ventricular dysfunction in acute pulmonary embolism? • RV wall hypokinesis – McConnell’s sign • RV dilatation – – – – End-diastolic diameter >30 mm in parastemal view RV larger than LV in sobcostal or apical view Increased tricuspid velocity >26 m/sec Paradoxical RV septal systolic motion • Pulmonary artery hypertension – Pulmonary artery systolic pressure >30 mmHg – Dilated IVC with lack of respiratory collapse Q4 What are the indications for thrombolysis in acute pulmonary embolism? • Most agree that cardiac arrest and haemodynamic instability (SBP < 90mmHg) are indications for thrombolysis • Controversy surrounds thrombolysis for stable patients with RV dysfunction on echocardiography – Treatment in this group has been shown to decrease pulmonary artery pressure and improve RV systolic function – Thrombolysis has not been shown to improve mortality – This benefit must be weighed against the risk of haemorrhage with thrombolytic therapy • Other treatment algorithms include the use of elevated Troponin and BNP to select which patients require urgent echocardiography • In haemodynamically stable patients with RV dysfunction, thrombolysis should be considered on a case-by-case basis Q5 What would you next? Administer thrombolysis – This patient has had a cardiac arrest from a pulmonary embolus and is potentially very unstable – She has severe RV dysfunction on echocardiography – There are no obvious contraindications to thrombolysis – Alteplase Cơ chế tác dụng?  Ái lực cao với fibrin  gắn kết nhanh với bất kỳ cục máu đông nào  Khi gắn được với fibrin, plasminogen chuyển thành plasmin  tan cục máu đông Chỉ định - Nhồi máu tim cấp (AMI) - Thuyên tắc phổi cấp (PE) - Đột quỵ nhồi máu não cấp (Activase – Genentech/ Roche (US/ Canada) & Actilyse – Boehringer 1996 Ingelheim (All others)) FDA Actilyse® (AMI) Actilyse® (PE) Actilyse® Stroke 1987 Launched 1994 Licenced 4/02 Conditional Approval 11/02-4/03 Ratifcation by member states i.e license Pulmonary embolism Contraindication  Evidence of severe bleeding  Severe liver insufficiency Few hours later • Echo was performed Q6 What was the response to treatment? This echo was performed a few hours later - Already some improvement in RV dysfunction is evident Thanks for your attention!!