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Figure: ultrasound, shortness of breath, tachycardia, McConnell's sign, enlarged right ventricle, acute pulmonary embolism, PE, septal wall, tricuspid annular plane systolic excursion, TAPSE, hemodynamic collapse
FigureA 45-year-old woman presented with shortness of breath.
She reported that she had easily become out of breath for a few days.
She had previously been healthy and active.
Her vital signs were a blood pressure of 110/60 mm Hg, a heart rate of 110 bpm, a respiratory rate of 20 bpm, a temperature of 99°F, and an oxygen saturation level of 96% on room air.
She appeared slightly uncomfortable and was tachycardic, but otherwise her exam was unremarkable.
Her bedside echo is shown.
What abnormalities do you note, and what additional ultrasound information will be helpful in determining her treatment?
Find a discussion on page 23.
Diagnosis: McConnell's Sign and Enlarged Right Ventricle
An apical four-chamber view demonstrated several findings consistent with right heart strain and was concerning for acute pulmonary embolism (PE) given the patient's history. Noted here are a markedly enlarged right ventricle and McConnell's sign. (See a video of this at http://bit.ly/VideosSound.) Not shown in this image but also consistent with right heart strain would be paradoxical septal wall motion (bowing of the septum inward toward the left ventricle).
Identifying submassive PE can be a challenge because many of these patients initially appear stable, but then they can go on to have hemodynamic collapse, a diagnosis that carries an in-hospital mortality rate of up to 15 percent. Risk stratification tools such as Hestia and PESI have become popular to determine which patients may be treated as outpatients. These tools do not, however, take echo findings into account and may overlook significant PE.
Figure: An apical four-chamber view demonstrating enlargement of the right ventricle (RV) in comparison with the left ventricle (LV). See a video demonstrating enlargement of the right ventricle in comparison with the left ventricle and McConnell's sign at
http://bit.ly/VideosSound.
To measure TAPSE, align the M mode caliper along the free wall of the RV so that it intersects the insertion of the tricuspid valve. Measure the resulting wave like tracing from peak to trough.
Tricuspid annular plane systolic excursion (TAPSE) can be helpful in risk-stratifying these patients and determining treatment and disposition. Put very basically, TAPSE measures how well the base of the right heart (at the insertion of the tricuspid valve) contracts toward the apex of the right ventricle during systole. The more it contracts, the better. The right heart will struggle to function in acute pulmonary hypertension, and the contractility will decrease. Some experts disagree, but a normal TAPSE should be greater than 16 mm.
A narrative review of the literature from 1950 to 2018 compared TAPSE with other measures of right heart strain and its predictive value as an aid in triaging patients with acute PE. (J Emerg Med. 2020;58[3]:449.) TAPSE is superior to other measurements, such as LV/RV ratio, primarily because it is a quantitative finding and less susceptible to user variability, with high interrater reliability. More importantly, a decreased TAPSE is a predictor of in-hospital mortality and length of stay in the ICU. A normal TAPSE predicts survival in patients who are normotensive.
TAPSE is not a complicated measurement to obtain and can add significant information in patients with acute PE. It is worth obtaining, particularly in those patients who initially appear stable.
Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns athttp://bit.ly/EMN-SpeedofSound.
