THE ROLE OF ULTRASONOGRAPHY IN THE DIAGNO SIS OF MODERATE TO SEVERE PULMONARY-EMBOLISM

The role of ultrasonography in the diagnosis of moderate to severe pul monary embolism. - Between November 1991 and June 1992, 50 patients su spected of pulmonary embolism (SP > 20 %) underwent Doppler echocardio graphy, venous Doppler ultrasonography and pulmonary angiography. Pulm onary embolism was confirmed by pulmonary angiography In all patients but 3 (2 pts: mean pulmonary pressure > 50 mmHg and 1 pt: mobile throm bus between the infundibulum and the main pulmonary artery). Two group s were identified on the basis of Miller's index: Group 1 : '' non-mas sive'' pulmonary embolism, Miller < 60 % (n = 18); Group 2: ''masive'' pulmonary embolism, Miller greater than or equal to 60 % (n = 29). Th e patient with thrombus in the main pulmonary artery and the two with high pulmonary pressures were included in Group 2. Venous Doppler ultr asonography was performed in 96 % (n = 48) of patients, including 90 % within the first 24 hours. No could be drawn between the two groups o n the basis of venous Doppler ultrasonography findings. A majority of patients had thrombosis of main collecting vessels (Group 1 = 75 %, Gr oup 2 = 78 %) and 10 % of patients had no venous thrombosis of the low er limbs. Doppler echocardiography was performed in all patients, incl uding 94 % (n = 47) within the first 24 hours. Dilatation of the left ventricle as well as analysis of septal contraction was evaluable in a ll patients except one of Group 2, because of poor technical quality a nd of artificial pacing. A RV/LV ratio > 0.60 was found in 97 % (30/31 ) of patients of Group 2 as compared with 39 % (7/18) in Group 1. Sept al kinetics were considered normal In 83 % (15/18) patients of Group 1 and ''paradoxical'' septal movement was seen in 74 % (23/31) of those of Group 2. The association of a RV/LV > 0.60 and of a ''paradoxical' ' septum had a positive predictive value of 92 % and a negative predic tive value of 88 % for the detection of ''massive'' PE. Only one throm bus was found in the cavities of the right side of the heart, i.e. in 2 % of patients. Doppler measurement of pulmonary systolic pressures d id not reveal any difference between the two groups. Doppler measureme nt of pulmonary systolic pressures and the detection of venous thrombo sis do not appear to be of any great value on an emergency basis in th e diagnosis of massive pulmonary embolism. In contrast, Doppler echoca rdiography appears to be an essential investigation for the diagnosis of massive pulmonary embolism. Thus in a clinical context suggestive o f recent thromboembolic disease, the simple information provided by Do ppler echocardiography (RV/LV ratio > 0.60 associated with ''paradoxia l'' septal movement) is essential for making the diagnosis of ''massiv e'' pulmonary embolism.