Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III Patients

Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III PatientsIt is well recognized that pulmonary embolism (PE) may be a difficult diagnosis to establish. The clinical manifestations are similar to those of other cardiopulmonary disorders, and, thus, the diagnosis of PE may not be considered even in patients presenting with classic symptoms. The characteristic symptoms and signs such as dyspnea, chest pain, tachypnea, and hypotension are not specific for a definitive diagnosis. Accurate diagnosis is important because untreated in-hospital mortality is up to 30 percent whereas it is only 8 percent if appropriately treated. Investigators have shown the presence of thromboemboli in the main pulmonary artery by transesophageal echocardiography (TEE) in patients diagnosed as having PE. canadian health & care mall

The clinical significance of incidentally detected PE by TEE and its impact on management is not known. We describe a group of critically ill patients in whom the clinical diagnosis of PE was not made, due to coexisting cardiopulmonary disorders, until TEE visualized clinically unsuspected central pulmonary artery thrombi. The purpose of this article is to (1) reaffirm that the clinical diagnosis of PE may be easily missed due to coexisting cardiopulmonary disorders and to emphasize how the diagnosis of PE could have been suspected by review of risk factors and the presence of right heart strain demonstrated by transthoracic echocardiography (TTE) (which had been obtained for the evaluation of the cardiopulmonary comorbidities), and, more pertinently, (2) to describe the impact of detecting clinically unsuspected central pulmonary artery thrombi by TEE on patient treatment and outcome. Fourteen patients in whom PE was not clinically suspected at the time of hospital admission and was diagnosed incidentally by TEE formed the study population.
There were 6 men and 8 women of mean age 61 years (range, 22 to 80 years). The medical records of these patients were reviewed for the following: (1) presenting symptoms and signs; (2) risk factors for PE; (3) initial diagnosis; (4) cardiopulmonary comorbidities; and (5) other diagnostic tests (ventilation/ perfusion scanning and pulmonary angiography). Indication for TEE in these 14 patients is shown in Table 1. Nine patients had biplane TEE and five patients had multiplane TEE.

Table 1—Clinical Features, Management, and Outcome of Patients

Case No./ Age, yr/ sex Presentation Diagnosis CardiopulmonaryDisorders RiskFactors Indication for TEE Confirmation Management Outcome
1/69/M Chest pain after aortic dissection repair Redissection Aortic dissection, CAD Major surgery Evaluate aortic graft +V/Q IV heparin Discharged
2/75/M Respiratory failure post-MVA, hypoxia ASD or PFO with right to left shunt DVT/PE, HTN History PE, immobilization post-MVA Possible intracardiac shunt +V/Q IV heparin Died
3/68/F Dyspnea, swelling lower extremity, hypoxia CHF CAD, CHF History DVT Possible intracardiac shunt +V/Q IV heparin Discharged
4/76/F Chest pain, dyspnea CHF HTN, CAD, CHF CHF Possible right atrial mass +V/Q IV heparin Discharged
5/61/M Dyspnea, CVA CHF HTN, CAD, CHF Immobilization, recent CVA Cardiac source of embolus +V/Q Oralanticoagulation Discharged
6/65/M Shock, hypoxia Cardiogenic shock CAD Immobilization, right hip fracture Left ventricular function +V/Q Greenfield filter Discharged
7/45/M Shock after valvular surgery Cardiogenic shock, prosthetic valve dysfunction CHF CHF, major surgery Left ventricular function, valvular integrity Autopsy Streptokinase Died
8/64/M Dyspnea, hypoxia, swelling lower extremity CHF secondary to LV dysfunction CHF CHF Evaluate MR prior to coronary artery bypass surgery Histology,embolectomy Embolectomy, IV heparin Discharged
9/37/M Dyspnea CHF, ? infective endocarditis Dilated CM, HTN CHF Evaluate RA mass Autopsy IV heparin Died
10/67/F Dyspnea, nausea, vomiting ? Pneumonia HTN, CAD Immobilization Suboptimal TTE Pulmonaryangiography Greenfield filter Discharged
11/22/F Cardiac arrest, respiratory failure ASD or PFO with right to left shunt None None Suboptimal TTE +V/Q IV heparin Died
12/80/F Cerebrovascular accident, dyspnea CHF, CVA HTN, CHF Immobilization RA mass, source of embolus +V/Q IV heparin Discharged
13/57/F Dyspnea, lower extremity swelling CHF Asthma, CHF Immobilization LV function +V/Q IV heparin Discharged
14/72/F Dyspnea, atrial fibrillation CHF, atrial fibrillation CHF, CAD CHF,immobilization LV function, suboptimal TTE +V/Q IV heparin Discharged
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