Point-of-care transthoracic echocardiography
Editor – The point is well made that increased use of computed tomography pulmonary angiography (CTPA) in patients with low pretest probability of pulmonary embolism (PE) might pose unnecessary risk of harm to patients, and might also be an inappropriate use of scarce resources. On the other hand, when pretest probability of PE is sufficiently high, based on the presence of symptoms, ultrasonographically validated deep vein thrombosis (DVT) and D-dimer cut-off levels compliant with those proposed by Tuck et al, identification of stigmata of PE by point-of-care transthoracic echocardiography (TTE) might be a satisfactory alternative to CTPA.1
The utility of point-of-care TTE as an alternative to CTPA was validated in anecdotal reports involving PE patients with cardiogenic shock or cardiac arrest.2–5 In all four instances, TTE showed right ventricular dilatation, which, in the context of cardiogenic shock, is highly predictive of PE or its close mimic, right ventricular myocardial infarction, the distinguishing feature of the latter being ST elevation in leads V4R–V7R.6,7 In all four instances, pre-test probability of PE was enhanced by ultrasonographic documentation of deep vein thrombosis.2–5 Most crucially, in all four instances, pre-emptive thrombolysis proved to be life-saving.
Stigmata of PE, which can be identified by TTE in haemodynamic crisis include not only right ventricular dilatation but also free floating right heart thrombus and McConnell's sign.2–5,8,9 In the latter contexts as well, CTPA can be deferred and pre-emptive thrombolysis initiated instead.8,9
Alternatively, emergency pulmonary embolectomy might be deployed, as was the case in a haemodynamically compromised PE patient in whom transoesophageal echocardiography showed McConnell's sign as well as impending paradoxical embolism characterised by a thrombus straddling a patent foramen ovale.10
- © Royal College of Physicians 2021. All rights reserved.
References
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- Tuck A
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- Bottinor W
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- Piggott Z
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- Ginghina C
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- Singh M
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- Worku B
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