1. Il paziente emodinamicamente instabile Andrea Barbieri U.O. Cardiologia Policlinico di Modena “ Il percorso diagnostico dell’embolia polmonare” Modena 14 novembre 2003

2. Chest 2002;121:877-905

3. Massive (major) pulmonary thromboembolism Defined as a > 50% obstruction of the pulmonary vasculature or the occlusion of two or more lobar arteries (without prior CPD) Any combination of embolus size and cardiopulmonary function that results in a hemodynamically significant event (with prior CPD) Only a minority of pts with anatomically massive PE will have hemodynamic instability Systolic arterial hypotension is the most significant prognostic indicator of outcome

4. Chest 2002;121:877-905

6. Massive (major) pulmonary thromboembolism without prior CPD BP = CO x SVR it is likely that hypotension will ensue when systemic vasoconstriction is inadequate to generate pressure in response to decreasing flow. Thus, it appears that there exists a hierarchic series of compensatory cardiovascular responses related to the magnitude of the embolic event, with hemodynamic instability defining exhaustion and the failure of the available compensatory measures.

7. Chest 2002;121:877-905

8. Massive (major) pulmonary thromboembolism: special considerations. Isolated RV dysfunction. The vast majority of pts survive It is imperative to more precisely define the subset of pts with a exceeding mortality rate 10% deteriorate into shock with 50% mortality rate attribuited to recurrent PE Recurrent PE vs RV dysfunction (identification of substantial DVT will be a discriminators?)

9. The natriuretic peptide family Am Heart J 1998;135:914-23

10. Key distinguishing features of the ventricular natriuretic peptides Rev Cardiovasc Med 2003;4:72-80

12. Accuracy of cardiac biomarkers for the prediction of in-hospital death in pulmonary embolism Circulation 2003;108:2191-2194

13. Mechanism of cardiac biomarker level elevation in pulmonary embolism Circulation 2003;108:2191-2194

14. Pulmonary embolism management strategy Circulation 2003;108:2191-2194

15. Submassive PE N Engl J Med 2002;347:1143-50

16. Submassive PE N Engl J Med 2002;347:1143-50

17. Submassive PE N Engl J Med 2002;347:1143-50

18. Circulation 2002;105:1416-19

19. Percutaneous emergency treatment J Am Coll Cardiol 2000;36:375-80

21. Echocardiographic signs used in diagnosis of acute pulmonary thromboembolism 1. Direct visualization of thrombus in the right- sided chambers or the pulmonary artery 2. Right ventricular dilation 3. Reduced right ventricular function 4. Reduced left ventricular cavity size 5. Dilated pulmonary arteries 6. Abnormal septal motion/systolic flattening of the septum 7. Significant (moderate to severe) tricuspid regurgitation 8. Increased velocity of tricuspid regurgitation jet 9. Dilation of the inferior vena cava

22. Massive (major) pulmonary thromboembolism without prior CPD The clinical and physiologic manifestation of the disease are directly related to embolism size Good correlation between the degree of angiographic obstruction and mPAP, RAP, PaO2 PA hypertension begins to manifest only when  25-30% of pulmonary vascular bed is obstructed Pts are unable to generate mPAP  40 mmHg mPAP is not a reliable predictor of cardiac impairment RAP of  10 mmHg is generated by an obstruction  50%

23. Massive PE N Engl J Med 1969;280:1194-99

24. Massive (major) pulmonary thromboembolism with prior CPD Level of mPAP is disproportionate to the degree of angiographic obstruction when compared to patients without prior CPD The predictive value of Pao2 and RAP to define the extent of the vascular obstruction is lost RAP is an unreliable indicator of the severity of the event mPAP/percentage of angiographic obstruction > 1

25. Abnormal Echocardiographic Findings in Patients with Pulmonary Embolism Abnormal Finding Right ventricular dilatation and hypokinesis Description the ratio of the right ventricular end-diastolic area to left ventricular end-diastolic area exceeds the upper limit of normal (0.6) Associated with right atrial enlargement and tricuspid regurgitation (2,5-3,5 m/s) Minimal collapse of the IVC with inspiration Regional pattern of RV dysfunction

29. Abnormal Echocardiographic Findings in Patients with Pulmonary Embolism Abnormal Finding Septal flattening and paradoxical septal motion Description Right ventricular contraction continues even after the left ventricle starts relaxing at end- systole; therefore, the interventricular septum bulges toward the left ventricle.

32. Abnormal Echocardiographic Findings in Patients with Pulmonary Embolism Abnormal Finding Direct visualization of pulmonary embolism Description Only if pulmonary embolism is large and centrally located; much more easily visualized on transesophageal than transthoracic echocardiography.

35. Massive (major) pulmonary thromboembolism: special considerations. Emboli-in-transit. European Cooperative Study classification (Eur Heart J 1989;10:1046-59): Type A (thrombi are long, thin, extremely mobile, characteristically found in RA, originate in peripheral deep venous system) HIGH RISK Type B (usually smaller, round or oval shaped, less mobile, arise in RV, commonly associated with known RV thrombogenetic abnormalities, ex CHF) GOOD PRGOGNOSIS INDEPENDENT OF TREATMENT TYPE

36. Right heart thrombi in pulmonary embolism J Am Coll Cardiol 2003;41:2245-51

37. Massive (major) pulmonary thromboembolism: special considerations. Cardiac arrest. Should be considered as a diagnosis in all patients experiencing nontraumatic cardiac arrest (MPE+AMI  70%) In case of echo performed during asystole, a paradoxical bulging of the SIV remain a useful sign (SIV normally occupies a central position in the unloaded nonbeating heart) Continuing CPR is advocated to allow for thrombolytic activity or to prepare for embolectomy (mechanically fracture, no increased rate of significant hemorragic complications)

39. Echocardiography and long-term prognosis Circulation 1999;99:1325-30