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← Section VI · Miscellaneous Topics (Role of Echo)
VI.C

Pulmonary Heart Disease

6 cards

Notes

Cor pulmonale

  • RV dysfunction secondary to pulmonary disease (Group 3 PH) or chronic pulmonary vascular disease.
  • Chronic: RV hypertrophy (wall > 5 mm), dilation, TR, elevated PASP, low TAPSE.
  • Acute (massive PE): thin-walled RV, TR jet velocity capped ~3.5 m/s, McConnell's sign.

Acute pulmonary embolism - echo signs

  • RV dilation (RV/LV basal diameter ratio > 1).
  • McConnell's sign - RV free-wall akinesis with apical sparing.
  • Septal flattening in systole (D-shaped LV).
  • Reduced TAPSE (< 17 mm).
  • Elevated TR jet velocity (but PASP typically capped at ~ 50–60 mmHg - unprepared thin-walled RV).
  • Thrombus in transit across RA/RV or in PA.
  • 60/60 sign - pulmonary AT < 60 ms + TR gradient < 60 mmHg suggests acute PE.

Chronic thromboembolic PH (CTEPH)

  • Sequela of unresolved PE.
  • Echo: RVH (wall > 5 mm), dilated RV, elevated PASP, right-heart strain.
  • Diagnosis confirmed with V/Q scan (mismatched perfusion defects), CT, or pulmonary angiography.
  • Definitive treatment: pulmonary thromboendarterectomy (PTE).

COPD-related PH

  • Group 3 PH.
  • Difficult to differentiate from CP-associated respiratory variation (mitral E ≥ 25% variation possible in both).
  • COPD: NON-restrictive mitral inflow + marked inspiratory increase in SVC forward flow.
  • CP: restrictive inflow + minimal SVC variation.

Pulmonary AV malformation

  • Right-to-left shunt at the pulmonary capillary level.
  • Bubble study: bubbles appear in LA after > 3 beats (4–8 cycles).
  • Associated with HHT (Osler-Weber-Rendu).
  • Cause of hypoxemia and paradoxical embolism/stroke.

Cards

  • basicVI.C-001
    Give three echo features of acute pulmonary embolism.
    → 1) RV dilation (RV/LV basal ratio > 1). 2) McConnell's sign (RV free-wall akinesis with apical sparing). 3) Septal flattening in systole (D-shaped LV). Also reduced TAPSE, moderately elevated TR jet velocity (typically capped ~ 3.5 m/s in acute PE).
  • basicVI.C-002
    What is the '60/60 sign' and what does it suggest?
    → Pulmonary AT < 60 ms AND TR peak gradient < 60 mmHg — suggests acute pulmonary embolism. The RV is unable to acutely generate high pressures against elevated PVR.
  • basicVI.C-003
    Definitive treatment for chronic thromboembolic pulmonary hypertension?
    → Pulmonary thromboendarterectomy (PTE) — surgical removal of organized thrombi from the pulmonary arteries. Riociguat and balloon pulmonary angioplasty are options for inoperable disease.
  • basicVI.C-004
    What condition should be suspected when a bubble study shows delayed (> 3 cardiac cycles) appearance of bubbles in the LA?
    → An intrapulmonary shunt — most commonly a pulmonary arteriovenous malformation. Frequently associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu).
  • basicVI.C-005
    State a common finding on echo that helps distinguish COPD from constrictive pericarditis.
    → COPD shows marked INSPIRATORY INCREASE in SVC forward flow (from exaggerated negative pleural pressure), whereas in constrictive pericarditis the SVC flow is minimally variable with respiration. Also, transmitral inflow is not restrictive in COPD.
  • basicVI.C-006
    What percentage of chronic PE patients develop CTEPH?
    → ~2–4% of survivors of acute PE develop chronic thromboembolic pulmonary hypertension.