Diagnóstico e acompanhamento terapêutico de pacientes com embolia pulmonar maçica através da ecocardiografia bidimensional / Diagnosis and follow-up of patients with massive pulmonary embolism by two dimensional echocardiog

RESUMO

Objetivo - Analisar a utilidade do ecocardiograma (ECO) no diagnóstico e no acompanhamento de pacientes com embolia pulmonar maciça (EP), submetidos à terapêutica fibrinolítica ou cirúrgica. Métodos - Foram incluídos retrospectivamente sete pacientes (cinco homens), com idade média de 37 ñ 19 anos, portadores de EP confirmada à angiografia. Seis foram submetidos à terapêutica fibrinolítica com estreptoquinase IV (EQ) e um à cirurgia. O diagnóstico definitivo de EP ao ECO foi a detecçäo de trombos no leito arterial pulmonar. Foram estudados diâmetro diastólico ventricular direito (DDVD), movimento do septo interventricular (SIV), tempo de aceleraçäo sistólico (TAC) e pressäo sistólica pulmonar (PSP). Resultados - O ECO identificou trombos em cinco dos sete pacientes (71//), principalmente quando localizados em artéria pulmonar direita (quatro casos (80//. Esse método foi ainda eficaz na identificaçäo de um dos cinco casos (20//) com trombose de ramos lobar direito e um de dois casos com comprometimento da artéria pulmonar esquerda (50//), sendo incapaz de localizar trombos em ramos lobares esquerdos (seis pacientes). Quatro dos cinco pacientes com trombos pulmonares ao ECO receberam EQ,, e um cirurgia. O ECO seriado mostrou dissoluçäo dos trombos em três daqueles com EQ e no caso com tratamento cirúrgico. O ECO inicial mostrou DDVD aumentado em 5/7 pacientes, movimento anômalo do SIV em 5/7 pacientes e TAC inferior a 100ms em todos os casos. A PSP foi 64,4 ñ 22,8mmHg ao ECO, versus 75,4 ñ 24,03mmHg à angiografia (r=0,78; p=0,11). Houve diminuiçäo do DDVD (30 ñ 5,02 para 23 ñ 2,2; p = 0,04) e aumento do TAC (50 ñ 10,8 para 106,67 ñ 16 ms; p < 0,001) no estudo seriado. Conclusäo - O ECO é um importante instrumento no diagnóstico de EP, fornecendo dados referentes à hemodinâmica pulmonar, à localizaçäo dos trombos e à evoluçäo terapêutica do paciente

ABSTRACT

Purpose - The aim of the study was to analyse the role of 2D echocardiogram (ECHO) in the diagnosis of massive pulmonary embolism (PE), and in the follow-up after fibrinolytic or surgical treatment. Methods - Echocardiographic studies were retrospectively analysed in seven patients, 5 male, meanage 37±19 years, with massive pulmonary embolism (PE) confirmed by pulmonary angiography. Six of them were submitted to fibrinolytic theraphy with IV streptokinase (SK), and one underwent surgery. The diagnosis of PE by ECHO was made by the detection of thrombi in the pulmonary vascular bed. ECHO measurements included the right ventricular diastolic diameter (RVDD), interventricular septal motion (IVS), acceleration time (AcT), and peak pulmonary artery pressure (PAP). Results - The ECHO study diagnosed thrombi in five out of seven patients (71%), mainly if they were present in the right main pulmonary artery (four cases - 80%). It was also able to locate one out of five patients with thrombus in the right lobar artery and one out of two patients in the left main pulmonary artery; it was unable to identify six patients with involvement of the left lobar arteries. Four out of five patients with PE, diagnosed by ECHO, were submitted to fibrinolytic therapy, and one underwent surgery. The follow-up study showed dissolution of the thrombus in three of those with SK and in the one with surgical treatment. The initial ECHO study showedf ve out of 7 patients with increased RVDD, 5/7 patients with abnormal IVS motion, and all of them with decreased AcT (64 ± 16 ms). The PSP was 64.4 ± 22.8 mmHg by ECHO, versus 75.4 ± 24,03 mmHg by angiography (r = 0.78; p = 0.11). There was a reduction of the RVDD (30 ± 5.02 to 23 ± 2.2) and an increased of the AcT (50 ± 10.8 to 106,67 ± 16) at the serial examination. Conclusion - The ECHO study is an important tool for the diagnosis of PE, informing about pulmonary pressure, presence and position of thrombus, and treatment results: