title: Regional right ventricular dysfunction in acute pulmonary embolism: relationship with clot burden and biomarker profile.
abstract: Regional right ventricular (RV) dysfunction (RRVD) is an echocardiographic feature in acute pulmonary embolism (PE), primarily reported in patients with moderate-to-severe RV dysfunction. This study investigated the clinical importance of RRVD by assessing its relationship with clot burden and biomarkers. We identified consecutive patients admitted to the emergency department between 1999 and 2014 who underwent computed tomographic angiography, echocardiography, and biomarker testing (troponin and NT-proBNP) for suspected acute PE. RRVD was defined as normal excursion of the apex contrasting with hypokinesis of the mid-free wall segment. RV assessment included measurements of ventricular dimensions, fractional area change, free-wall longitudinal strain and tricuspid annular plane systolic excursion. Clot burden was assessed using the modified Miller score. Of 82 patients identified, 51 had acute PE (mean age 66 ± 17 years, 43% male). No patient had RV myocardial infarction. RRVD was present in 41% of PEs and absent in all patients without PE. Among patients with PE, 86% of patients with RRVD had central or multi-lobar PE. Patients with RRVD had higher prevalence of moderate-to-severe RV dilation (81 vs. 30%, p < 0.01) and dysfunction (86 vs. 23%, p < 0.01). There was a strong trend for higher troponin level in PE patients with RRVD (38 vs. 13% in PE patients without RRVD, p = 0.08), while there was no significant difference for NT-proBNP (67 vs. 73%, p = 0.88). RRVD showed good concordance between readers (87%). RRVD is associated with an increased clot burden in acute PE and is more prevalent among patients with moderate-to-severe RV enlargement and dysfunction.
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: Mirela
authors.initials: M
authors.lastname: Tuzovic
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: Sasikanth
authors.initials: S
authors.lastname: Adigopula
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA. myriam.amsallem@gmail.com.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA. myriam.amsallem@gmail.com.
authors.forename: Myriam
authors.initials: M
authors.lastname: Amsallem
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: Yukari
authors.initials: Y
authors.lastname: Kobayashi
authors.affiliation: Division of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Kadoch
authors.affiliation: Unité de Recherche Clinique, Marie Lannelongue Hospital, University of Paris XI, Le Plessis Robinson, France.
authors.forename: David
authors.initials: D
authors.lastname: Boulate
authors.affiliation: Center for Clinical Informatics, Stanford University Medical Center, Palo Alto, CA, USA.
authors.forename: Gomathi
authors.initials: G
authors.lastname: Krishnan
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Liang
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: Ingela
authors.initials: I
authors.lastname: Schnittger
authors.affiliation: Division of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Dominik
authors.initials: D
authors.lastname: Fleischmann
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: Michael V
authors.initials: MV
authors.lastname: McConnell
authors.affiliation: Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.|Stanford Cardiovascular Institute, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, USA.
authors.forename: François
authors.initials: F
authors.lastname: Haddad
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D001696:Biomechanical Phenomena; D001777:Blood Coagulation; D002140:California; D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D015588:Observer Variation; D010446:Peptide Fragments / Q000097:blood*; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D014336:Troponin / Q000097:blood*; D018497:Ventricular Dysfunction, Right / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D016278:Ventricular Function, Right
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D014336:Troponin; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
keywords: Echocardiography; McConnell sign; Pulmonary embolism; Regional right ventricular dysfunction