Ivičić Toni, Hamzić Jasmin, Radulović Bojana, Gornik Ivan
Emergency Department, University Hospital Centre, Zagreb, Croatia.
Ultrasound J. 2024 Dec 18;16(1):51. doi: 10.1186/s13089-024-00377-2.
Pulmonary embolism (PE) is one of the most challenging diagnoses in emergency medicine, mainly because symptoms range from asymptomatic disease to sudden death. The role of echocardiography in the workup of suspected PE has been supportive and used primarily to assess the right ventricular (RV) size and function, which is important for risk stratification. Several echocardiographic parameters described in the literature lack the desired accuracy. Recently, a potential value of less well-recognized RV outflow tract (RVOT) Doppler variables has been reported. The early systolic notching (ESN) pattern was observed in 92% of patients with high and intermediate risk PE, making it a promising sign in selected PE patients.
In this case series, we demonstrate a typical ESN pattern on RVOT Doppler evaluation in three patients with intermediate-risk PE presenting to our emergency department (ED). None of the patients had been previously diagnosed with pulmonary hypertension or other chronic pulmonary and cardiac disease. The pre-test probability was low. Massive proximal emboli were found on CT angiograms, involving pulmonary truncus or main pulmonary arteries. Previously, the ESN pattern was identified on a focused echocardiogram, which was the only echocardiographic indicator of increased pulmonary vascular resistance.
RVOT Doppler flow pattern of ESN has potential clinical utility for the detection of PE in ED patients. ESN could identify patients at higher risk, which are otherwise stratified as low risk according to the latest guidelines. Moreover, this case series illustrates that even in the absence of other echocardiographic findings of RV strain, the presence of ESN should alert to the possibility of acute PE. Further prospective studies are needed to assess its diagnostic value in a selected subgroup of patients, similar to the cases presented, that would have no other obvious reason for the altered RVOT Doppler curve.
肺栓塞（PE）是急诊医学中最具挑战性的诊断之一，主要原因是其症状范围从无症状疾病到猝死。超声心动图在疑似PE的检查中起辅助作用，主要用于评估右心室（RV）大小和功能，这对风险分层很重要。文献中描述的几个超声心动图参数缺乏所需的准确性。最近，有报道称一些不太被认可的RV流出道（RVOT）多普勒变量具有潜在价值。在92%的高风险和中度风险PE患者中观察到早期收缩期切迹（ESN）模式，这使其成为特定PE患者中有前景的体征。
在本病例系列中，我们展示了三名中度风险PE患者在我院急诊科接受RVOT多普勒评估时的典型ESN模式。这些患者之前均未被诊断患有肺动脉高压或其他慢性肺部和心脏疾病。预检概率较低。CT血管造影显示存在大量近端栓子，累及肺动脉干或主肺动脉。此前，在床旁超声心动图上发现了ESN模式，这是肺血管阻力增加的唯一超声心动图指标。
ESN的RVOT多普勒血流模式在急诊科患者PE检测中具有潜在临床应用价值。ESN可识别出风险较高的患者，否则根据最新指南这些患者会被分层为低风险。此外，本病例系列表明，即使没有其他RV应变的超声心动图表现，ESN的存在也应提醒注意急性PE的可能性。需要进一步的前瞻性研究来评估其在选定患者亚组中的诊断价值，类似于所呈现的病例，这些患者没有其他明显原因导致RVOT多普勒曲线改变。
