**1.4.7 Echocardiography**

#### *Transthoracic echocardiography*

Echocardiography is a useful bedside non-invasive procedure in the differential diagnosis of various conditions (acute myocardial infarction, aortic dissection, pericardial tamponade,

Pathophysiology, Diagnosis and Treatment of Pulmonary

BNP ↓and Troponin↓

poor outcome.

**1.5 Therapy** 

**1.5.1 Acute therapy** 

based on biomarkers and echocardiography.

Embolism Focusing on Thrombolysis - New approaches 125

increased marker levels. Echocardiography results correlate showing a decreased RV function. Negative troponin results are good predictors of favourable outcome. Both markers are useful and independent predictors of the 30 days mortality. Impaired RV function with increased troponin and BNP are relative indications of thrombolysis (TL) therapy in the intermediate risk group (Giannitsis et al., 2000; Kostrubiec et al., 2005; Krüger et al., 2004; ten Wolde et al., 2004; Worth, 2009). The recommended therapeutic approach according to Kucher and Goldhaber based on these data (Kucher & Goldhaber, 2003):

**without shock shock**

Anticoagulant treatment Immediate thrombolysis or embolectomy

Fig. 2. Kucher and Goldhaber recommendation for the treatment of pulmonary embolism

Cases with severe haemodynamic shock present elevated lactate and metabolic acidosis due to global microcirculatory impairment and tissue hypoxaemia. These markers can predict

According to the recent guidelines, the diagnosis of PE is mainly based on the results of

For main therapeutic recommendations, we follow the ESC 2008 guidelines (Torbicki et al., 2008). Anticoagulation therapy should be initiated upon suspicion of PE. 5000 IU Na-heparin is recommended as intravenous bolus if the patient had not already received Low Molecular Weight Heparin (LMWH) previously. Besides providing secure venous access, patients should receive immediate oxygen therapy through a 50% or 100% face mask. The indication of oxygen therapy is absolute, but mechanical ventilation should be used with caution. Mechanical ventilation may decrease the venous reflow and increases RV insufficiency, therefore, low tidal volume (7 ml/kg) ventilation and intravenous fluid therapy is recommended. The alveolar-arterial gas exchange can also be impaired as shunt-flow and cardiac output decrease (Singer, M; Webb, 2004; Sevransky et al., 2004). Capnometry is highly recommended during mechanical ventilation, as it may change due to thrombolysis

BNP ↑and Troponin ↑

Echocardiography

without RV dysfunction RV dysfunction

echocardiography, MDCT and biomarkers (Torbicki et al., 2008).

chest pain, valve dysfunction, hypovolaemia). The sensitivity of echocardiography is about 60-70% in PE. Negative results do not exclude PE. Acute massive PE has characteristic echocardiography signs: RV hypokinesis and/or dilatation, the end diastolic diameter of the RV in the parasternal short axis > 30 mm, or RV/LV end diastolic diameter ratio > 0.9, in the apical or subcostal axis, D-sign, increased pulmonary arterial pressure, dilatation of the inferior caval vein. A heart cavity thrombus, patent foramen ovale (with the risk of paradox thrombi), tricuspidal valve thrombosis or vegetation and floating clot in the right ventricle can also be visualised.

The positive echocardiographic result has a predictive value in haemodynamically stable patient, as the intermediate risk group has worse outcome (Konstantinides, 2008; Torbicki et al., 2003; Ferrari et al., 2005; Hsiao et al., 2006; Casazza et al., 2005; Bova et al., 2003; Miniati et al., 2001; Roy et al., 2005; Konstantinides et al., 1998).

#### *Transoesophageal echocardiography*

The transoesophageal echocardiography is a semi-invasive diagnostic procedure, which can be useful in mechanically ventilated patients. Benefits of the transoesophageal approach are: visualisation of thrombi in the pulmonary trunk and/or main pulmonary arteries and also in the caval vein. Possible tumours originating from the heart or floating into the cavities of the heart can also be visualised (Sanchez et al., 2008).
