CME INDIA Case Presentation by Dr. Deepak Gupta, DM Card, Pulse Hospital, Ranchi.

CME INDIA Case Study

(Inputs from CME INDIA and CSI-Jharkhand groups)

36 Year-Old-Male with Severe Chest Pain and SOB for 3 Days

What is the ECG impression?

Dr. Saurav Kumar, Physician, Dhanbad:

  • S1Q3T3, Pulmonary Embolism.

Dr. Banumathy Shrikant:

  • Pulmonary embolism, S1Q3T3 seen.

Dr. Deepak Gupta:

  • Trop T-Negative. Echo clip follows:

Dr. Arun Kedia, Diabetologist, Raipur:

  • McConnell sign appears positive, Right chambers dilated, significant TR, Classic ECG all suggest massive PE.

 Dr. Venkatesh Molio, Maregoan, Goa:

  • Agree fully.

 Dr. Keyur Acharya, Intensivist, UK:

  • S1 Q3 T3 – what is its sensitivity and specificity? Except in very obvious cases, is this not a bit non-specific?

 Dr. Arun Kedia:

  • Around 30%.

Dr. Praveen Shukla, DM, Card., Kolkata:

  • RV free wall hypo kinetic.
  • It’s pulmonary embolism.
  • Also, S1Q3T3 pattern.

Dr. Deepak Gupta:

  • RVSP is visible in above echo. It is around 70 mmHg.
  • D Dimer also more than 3000.
  • CT Angiography follows.
  • What should be treatment plan?

36 Year-Old-Male with Severe Chest Pain and SOB for 3 Days
36 Year-Old-Male with Severe Chest Pain and SOB for 3 Days
36 Year-Old-Male with Severe Chest Pain and SOB for 3 Days

Dr. Praveen Shukla:

  • Catheter directed suction or thrombolysis.

Dr. Deepak Gupta:

  • What is indication of thrombolysis in pulmonary embolism?
    1. Iv Anticoagulant
    2. Thrombolysis( systemic or catheter based)
    3. Suction thrombectomy.

Dr. Ashish Ranjan Jha, Ranchi:

  • Cause of pulmonary thromboembolism in a 36-year-old patient?
  • Chest pain is not very common.
  • Obviously, echo is very diagnostic.
  • 50 50 sign, large RA, RV.

Dr. Deepak Gupta:

  • There are two imp indications of thrombolysis:
    1. Hypotension.
    2. RV dysfunction.
  • Here in this case there is RV hypokinesia with RV dilatation. BP was 110 / 70 mmHg.
  • Thrombolysis is indicated in this case.
  • Patient attendant refused thrombolysis moment we asked for consent explaining the risk of thrombolysis.
  • Therefore, patient was kept on Enoxaparin.
  • If any relative contraindication for systemic thrombolysis, it is better to give catheter base thrombolysis as it required low dose of thrombolytic agent.
  • We also have to find the cause of spontaneous clot formation. No clinical evidence of leg vein thrombosis is there.
  • Detailed investigations needed to find the cause of spontaneous thrombosis.
  • Catheter directed thrombolysis seems to have similar outcomes with Suction thrombectomy in the management of acute PE, although larger, much data are not available. Suction thrombectomy should be viewed as a complementary or alternative for patients with contraindication for thrombolytics or severely compromised hemodynamic profile and can yield good outcomes in an otherwise highly morbid population.

 Dr. Satish Kumar, Cardiologist, Bokaro:

 Dr. Rajesh Jha, DM Card., Raj Hospital, Ranchi:

  • Very interesting case.
  • Hypotension with sinus tachycardia on ECG with echo finding of PE is itself indication for thrombolysis. In this case, we can do thrombolysis without pulmonary Angio also.
  • I am having experience of thrombolysing with Tenecteplase in more than 30 case in last 6 years. Single shot dose; gives very good result. Catheter based thrombolysis or mechanical thrombectomy is not advocated to use now a days. Rightly said by you that should be used where contradiction to thrombolysis.

Dr. Arun Sarkar, Cardiologist Physician, Ranchi:

  • These are basic learning of Echo cardiography everybody should know. Hemodynamic assessment and RV performance are important determinant in clinical decision-making evaluation.

CME INDIA Learning Points

  • A timely diagnosis of pulmonary embolism is crucial.
  • It is associated with high mortality and morbidity.
  • It may be prevented with early treatment.
  • ECG Findings in PE:

36 Year-Old-Male with Severe Chest Pain and SOB for 3 Days
Sinus tachycardia – the most common.
Complete or incomplete RBBB 
Right ventricular strain pattern –  T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF). This pattern is associated with high pulmonary artery pressures.
Right axis deviation – Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation (“pseudo left axis”).
Dominant R wave in V1 – a manifestation of acute right ventricular dilatation.
Right atrial enlargement (P pulmonale) – peaked P wave in lead II > 2.5 mm in height.
SI QIII TIII pattern – deep S wave in lead I, Q wave in III, inverted T wave in III (seen in 20%). This “classic” finding is neither sensitive nor specific for PE.
Clockwise rotation – shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation.
Atrial tachyarrhythmias – AF, flutter, atrial tachycardia.
Non-specific ST segment and T wave changes, including ST elevation and depression.
  • It is worth to remember that in around 18% of patients with PE may have completely normal ECG.
  • Believe on compatible clinical picture (sudden onset pleuritic chest pain, hypoxia), an ECG showing new RAD, RBBB, or S1Q3T3 or T-wave inversions may raise the suspicion of PE.
  • Diagnostic Pearls:
  • CXR: Classic focal oligemia is seldom seen. ‘Westermark sign’ may be seen in up to 2% of the cases. This finding is a result of a combination of dilation of the pulmonary artery proximal to the thrombus and the collapse of the distal vasculature. Hampton’s hump is a shallow, hump-shaped opacity on CXR in the periphery of the lung, with its base lying against the pleural surface and hump towards the hilum.
  • ECG: Usually abnormal in 80%, but not specific and non-diagnostic.
    • Traditional Pulmonary angiography has been the gold standard and it is invasive and expensive.
    • D-dimer testing has high negative predictive value; hence, a normal D-dimer level makes acute PE or DVT unlikely.
    • V/Q scans: It is safe and available, unfortunately 35% of cases are considered non-diagnostic.
    • CTPA: Computed Tomographic Pulmonary Angiography- the most common, available, rapid, cost effective and highly accurate.
    • Transthoracic echocardiography: True sensitivity and specificity of TTE in diagnosing acute PE is difficult to assess. Reported sensitivities ranges from 60% – 90%, and specificities from 80% – 95%.
      • Direct visualization of thromboemboli in the RT heart and PA.
      • RV dilatation.
      • RV dysfunction.
      • Normal or hyper dynamic LV.
      • Septal flattening.
      • PA dilatation.
      • Unusual degree of TR or PR.
      • Increased PA pressure.
      • McConnell’s sign – an early and specific indicator of acute pulmonary embolism. It is the regional wall motion abnormality of the basal and mid right ventricular free wall with apical hyper contractility (McConnell’s sign) It is a distinct echocardiographic feature of acute massive pulmonary embolism. 
      • The 60/60 sign-the combination of a pulmonary ejection acceleration time (measured in the RV outflow tract) less than 60ms with a peak systolic tricuspid valve gradient less than 60 mmHg (’60/60′ sign),
      •  RVOT midsystolic notching.
  • Unexplained hypoxemia with a normal chest radiograph should raise the clinical suspicion for pulmonary embolism (PE). Widened alveolar-arterial gradient for oxygen, respiratory alkalosis, and hypocapnia are commonly seen findings on ABG, as a pathophysiological response to pulmonary embolism.
  • Management Pearls:
  • Acute RV failure is the leading cause of death in patients with hemodynamically unstable PE.
  • Do not venture for aggressive volume resuscitation in such patients as it can over distend the RV, worsen ventricular interdependence, and reduce cardiac output (CO).
  • In patients with massive PE, intravenous fluid resuscitation should be tried only in patients with collapsible IVC/intravascular depletion.
  • The mainstay of treatment of acute PE is anticoagulation.
  • Either low-molecular-weight heparin (LMWH) or fondaparinux or unfractionated heparin (UFH) can be used for anticoagulation in acute PE.
  • LMWH and fondaparinux are preferred since they have a less incidence of inducing major bleeding and heparin-induced thrombocytopenia.
  • UFH is usually only used in patients with hemodynamic instability in whom primary reperfusion treatment might be required, or in patients with renal impairment.
  • Newer oral anticoagulants (NOACs) and vitamin K antagonists(VKA) can also be used for anticoagulation in PE.
  • For patients with suspected PE, the treatment is stratified according to the type of PE. Assess whether patient  is hemodynamically stable or unstable PE.
  • Anticoagulation can be  started even before diagnostic imaging is obtained if there is  a high clinical suspicion for PE.
  • If low clinical suspicion for PE diagnostic imaging can be performed within 24 hours.
  • For patients in whom anticoagulation is contraindicated, IVC filter placement should be considered once the diagnosis of PE is confirmed.
  • Patients with a high clinical suspicion for PE who are hemodynamically unstable:
    1. Emergent CTPA
    2. Portable perfusion scanning or
    3. Bedside transthoracic echocardiography
    4. Primary reperfusion treatment, usually, thrombolysis, is the treatment of choice
    5. Surgical pulmonary embolectomy or percutaneous catheter-directed therapy are alternative reperfusion options in patients with contraindications to thrombolysis.
  • Thrombolysis is preferred when therapy can be instituted within 48 hours of symptom onset, but it has still shown benefit in patients whose symptoms began less than 14 days ago
  • Absolute contraindications to thrombolysis:
    • Any prior intracranial hemorrhage,
    • Known structural intracranial cerebrovascular disease (e.g., arteriovenous malformation),
    • Known malignant intracranial neoplasm,
    • Ischemic stroke within three months,
    • Suspected aortic dissection,
    • Active bleeding or bleeding diathesis,
    • Recent surgery encroaching on the spinal canal or brain
    • Recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury.
  • Catheter-Directed Treatment:
    • Insertion of a catheter into the pulmonary arteries,
    • Used for ultrasound-assisted thrombolysis, suction embolectomy, rotational embolectomy, thrombus aspiration, or combining mechanical fragmentation with pharmacological catheter-directed thrombolysis.
    • Different studies have shown a success rate of up to 87% for catheter-directed therapies.
  • Surgical Embolectomy:
    • Indicated in a patient with hemodynamically unstable PE  in whom thrombolysis (systemic or catheter-directed) is contraindicated,
    • or in patients who have failed thrombolysis.

CME INDIA Tail Piece

  • The term “embolism” is credited to Virchow.
  • In 1872, Trendelenburg, a noted German surgeon and founder of the German Surgical Society, realized the sudden mortality associated with this condition while reviewing the deaths of 9 patients from pulmonary embolism at the hospital at Leipzig.

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