# Clinical Application of Echocardiography in Evaluating Left Ventricular Diastolic Function in Patients with Acute Pulmonary Embolism

Authors: Shiyang Qin; Rui Zhang
Journal: Computational and Mathematical Methods in Medicine
 (2022)

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## Abstract

Objective. To explore the clinical application of echocardiography in assessing left ventricular diastolic function in patients with acute pulmonary embolism (APE). Methods. About 90 patients with APE treated in our hospital from March 2016 to March 2019 were enrolled as the study group. The enrolled patients were assigned into three groups in accordance with the risk stratification of APE, with 30 patients in each group, including high-risk group, medium-risk group, and low-risk group. Approximately 90 healthy persons who underwent physical examination in the same period were enrolled as the control group. The two groups were used to analyze the clinical value of echocardiography in evaluating left ventricular diastolic function in patients with APE and to explore the correlation between left ventricular diastolic function and different risk stratification of APE. Results. First of all, we compared the side values of echocardiography. Compared to the control group, right ventricular end-diastolic diameter/left ventricular end-diastolic diameter (RVED/LVED) and pulmonary artery systolic pressure (PASP) in the study group were higher, while left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular volume per stroke (LVSV), and left ventricular ejection fraction (LVEF) in the study group were lower (P<0.05). Secondly, we compared the echocardiographic side values of patients with different APE risk stratifications: (1) RVED/LVED, PASP: low‐riskgroup<medium‐riskgroup<high‐riskgroup; (2) LVEDV, LVESV, LVSV, LVEF: low‐riskgroup>medium‐riskgroup>high‐riskgroup (P<0.05). The routine echocardiographic findings of APE patients: M-type left ventricular wave group of pulmonary embolism (PE) indicated right ventricular enlargement and interventricular septum shifted to the left ventricle; short-axis section of PE artery indicated thrombosis at the opening of the right pulmonary artery (indicated by arrow); long-axis section of the left ventricle of PE indicated right ventricular enlargement (RV 3.5 cm, LV 3.9 cm); four-chamber view of PE indicated enlargement of the right atrium and the right ventricle, and interventricular septum shifted like left ventricle. In terms of mitral annulus displacement, early diastolic ESD and ELD in the study group were lower compared to those in the normal control group, while late diastolic ASD and ALD in the study group were higher compared to those in the normal control group (P<0.05). The results of Pearson correlation analysis indicated that there was a positive correlation between RVED/LVED, PASP, and APE risk stratification, while APE risk stratification was negatively correlated with LVEDV, LVESV, LVSV, and LVEF (P<0.05). Conclusion. Echocardiography attaches importance to the evaluation of left ventricular diastolic function in APE. The side value of echocardiography can sensitively reflect the changes of left ventricular diastolic function in APE. The predictive value in the diagnosis of APE is better than other traditional parameters of left ventricular diastolic function, especially in patients with different APE risk stratifications. There is a remarkable correlation between the changes of left ventricular diastolic function and different APE risk stratifications. Echocardiographic measurement can be employed to assess left ventricular diastolic function in APE, which can be developed in clinical treatment and prognosis evaluation to provide a new evaluation method.


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## Body

## 1. Introduction

Acute pulmonary embolism (APE) is a series of pathophysiological syndromes caused by endogenous or exogenous emboli blocking the pulmonary circulatory system, containing fat embolism syndrome, pulmonary thromboembolism, air embolism, amniotic fluid embolism, and tumor embolism [1]. Pulmonary thromboembolism is the most common type of APE in clinic, which usually occurs in the exfoliation of deep venous thrombosis (DVT) of lower extremities [2]. Pulmonary thromboembolism and DVT often exist in the meantime, so they are collectively referred to as venous thromboembolism (VTE). PE is a common cardiovascular disease, whose incidence is second only to coronary heart disease and hypertension, and it is also the third most cardiovascular fatal disease [3]. Epidemiological data in China indicate that the incidence of PE is increasing year by year. From 1997 to 2008, the nosocomial incidence of PE increased from 0.03% to 0.14% and increased with patients’ age. PE has dangerous onset, atypical symptoms, and lack of specificity. The clinical manifestation mainly depends on the size and the number of emboli, the location of embolism, and whether it is complicated with cardiopulmonary diseases. It is easy to be misdiagnosed, and the mortality rate is high [4]. The incidence of PE is estimated to be 11.2%, and about 100,000 people die from PE each year in the United States [5]. In Europe, 34% of VTE patients die from APE of about 370,000 VTE-related deaths, of which only 7% of PE patients are diagnosed before death [6]. The risk factors of PE embolism include DVT of lower extremities caused by long-term bed rest, operation, trauma, obesity, pregnancy, and oral contraceptive [7]. The prognosis of PE is poor. The 30-day all-cause mortality rate ranges from 9% to 11%. The risk of recurrence is high as well after stopping anticoagulants. The recurrence rate is 13% after 1 year [8, 9]. Clinically, we adopt a simple and easy “three-step” diagnosis strategy for APE management, emphasizing early risk stratification, gradual examination and clear diagnosis, and timely intervention and treatment [10]. The prognosis of APE is closely related to the degree of embolism. In order to make appropriate drugs and interventional treatment for patients with APE, it is necessary to redefine the subtype of APE.With more attention to left ventricular diastolic function, more clinical evidence indicates that the change of left ventricular diastolic function is a crucial factor in the morbidity and mortality of cardiovascular diseases, such as heart failure, pulmonary hypertension, PE, cardiomyopathy, and congenital heart disease. Therefore, the evaluation of left ventricular diastolic function is very crucial for the clinical management and prognosis of cardiovascular disease [11]. The American Heart Association divides PE into large area PE, sublarge area PE, and low-risk PE according to the clinical manifestations of APE and whether it is complicated with left ventricular diastolic function and circulatory failure [12]. The early detection and accurate evaluation of left ventricular diastolic function in patients with APE are very important for diagnosis, selection of treatment, and prognosis. At present, there are many methods to evaluate left ventricular diastolic function, containing laboratory examination, electrocardiogram, and imaging examination [13]. The common laboratory tests include troponin, brain natriuretic peptide (BNP), and creatine kinase isoenzyme (CK-MB). Troponin can sensitively reflect the impairment of left ventricular diastolic function and contribute to the risk stratification and prognosis evaluation of APE [14]. BNP is an indicator of cardiac insufficiency or heart failure, indicating the transition of left ventricular diastolic function from compensatory to decompensated. It is found that CK-MB has a higher value in predicting APE mortality, but the positive rate is lower, so it is not used as a routine prognostic index [15]. Cardiac biomarkers can sensitively reflect left ventricular diastolic function, but the diagnostic cutoff values vary greatly with the passage of time, and the specificity is poor. The main electrocardiographic manifestations of APE patients were T wave inversion in precordial leads and limb leads, depression of ST segment, QR type in V1, SI QIII TIII, and incomplete or complete left ventricular branch block, which were more common in high risk with APE patients. Fragmented QRS (fQRS) on ECG is of potential value in predicting PE. Patients with low risk of APE may exhibit atrial arrhythmias [16]. The electrocardiogram of APE lacks specificity and is often misdiagnosed as coronary heart disease. There are many indexes for quantitative evaluation of left ventricular diastolic function in APE by echocardiography, and each has its own advantages and disadvantages. Therefore, echocardiography can be employed as a reference for risk assessment of APE. At present, in the clinical management guidelines of PE, the ultrasonic diagnostic criteria of left ventricular diastolic function in APE are not clear. For patients with suspected APE who are hemodynamically stable, risk stratification is recommended, followed by selective echocardiography. With the development of ultrasound technology and the deeper understanding of left ventricular diastolic function, more ultrasonic parameters are applied to the evaluation of left ventricular diastolic function in patients with APE. The aim of this study is to dynamically monitor the left ventricular diastolic function of APE by echocardiography in order to provide a new method for clinical treatment and prognosis evaluation of left ventricular diastolic function in patients with APE.


## 2. Patients and Methods

### 2.1. General Information

About 90 patients with APE treated in our hospital were enrolled as the study group from March 2016 to March 2019. The enrolled patients were assigned into three groups according to the APE risk stratification, with 30 patients in each group, containing high-risk group, medium-risk group, and low-risk group. A total of 90 healthy persons who underwent physical examination in the same period were enrolled as the control group. In the control group, the age was 43-74 years old, with an average age65.91±3.63, containing 36 males and 54 females, while in the study group, the age was 44-76 years old, with an average age 65.96±3.58, containing 35 males and 55 females. There exhibited no statistical significance in the general data. This study was permitted by the Medical Ethics Association of our hospital, and all patients provided informed consent.APE risk stratification criteria are [17] as follows: (1) high risk level: shock or systemic hypotension; (2) moderate risk level: no shock or systemic hypotension, but right ventricular insufficiency and/or myocardial injury; the main clinical manifestations of right ventricular insufficiency are abdominal distension, loss of appetite, nausea, vomiting, and fatigue dyspnea caused by liver stasis; (3) low risk level: there was neither shock nor right ventricular insufficiency or myocardial injury.Diagnostic criteria: to observe whether the echocardiographic signs of thrombus in the right atrium, right ventricle, pulmonary artery trunk, and bifurcation can be observed by echocardiography, whether the indirect signs of increased pulmonary artery pressure, decreased activity of right ventricular wall, and increased right cardiac load could be observed.Inclusion criteria: (1) APE was confirmed by pulmonary angiography or pulmonary CTA; (2) blood gas analysis indicated hypoxemia; plasma D-dimer was positive; APE was diagnosed according to its symptoms, signs, ultrasound, and laboratory examination.Exclusion criteria: patients with poor ultrasound window, thrombolysis taboo, and other heart and lung diseases.


### 2.2. Treatment Methods

All patients were examined by echocardiography: emergency echocardiographic examination was performed in all patients with echocardiographic diagnostic equipment (manufacturer: Philips; model: PHILIPSEPIQ7C/PHILIPSIE33). The examination included parasternal artery short-axis section, parasternal left ventricular long-axis section, parasternal four-chamber view, and apical four-chamber view. The transverse and anterior-posterior diameters of left ventricle and right ventricle at the end of diastole were measured. The transverse diameter of the right atrium, the transverse diameter of the left atrium and the anterior and posterior diameter of the left atrium at the end of systole, the width of the main pulmonary artery at the end of systole, the amplitude of motion of the anterior wall of the right ventricle, the posterior wall of the left ventricle, and the interventricular septum were compared, whether there are thrombus echo signs in the right atrium, right ventricle, pulmonary artery trunk, and bifurcation.


### 2.3. Observation Index

#### 2.3.1. Echocardiographic Value

Left ventricular end-diastolic diameter (LVED), right ventricular end-diastolic diameter (RVED), and pulmonary artery systolic pressure (PASP) were calculated and evaluated by measuring right atrial pressure and maximum tricuspid regurgitation pressure difference. Patients were instructed to hold their breath, and S5-1 probe was used to measure left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular volume per stroke (LVSV), and left ventricular ejection fraction (LVEF) at apical four-chamber and two-chamber views by Simpson’s biplane method.


#### 2.3.2. Mitral Annulus Displacement

The early diastolic posterior septal displacement (ESD) and the left ventricular lateral wall displacement (ELD) of early diastolic mitral annulus were measured automatically by taking two points at the beginning and end of early diastole on the motion curves of the two sites. Similarly, the late diastolic mitral annulus posterior septal displacement (ASD) and late diastolic left ventricular lateral wall displacement (ALD) were automatically measured on the motion curve at two points at the beginning and end of late diastole.


### 2.4. Statistical Analysis

The data of this study were analyzed by SPSS 26.0; the counting data were presented byn%. The chi-square partition method was employed for the pairwise comparison, and the measurement data of normal distribution was presented by (x¯±s). The comparison was assessed by independent sample T-test, the correlation of normal distribution data was analyzed by Pearson’s correlation analysis, and the correlation between skewed distribution data and grade data was analyzed by Spearman correlation analysis. The difference exhibited statistical significance (P<0.05).


## 2.1. General Information

About 90 patients with APE treated in our hospital were enrolled as the study group from March 2016 to March 2019. The enrolled patients were assigned into three groups according to the APE risk stratification, with 30 patients in each group, containing high-risk group, medium-risk group, and low-risk group. A total of 90 healthy persons who underwent physical examination in the same period were enrolled as the control group. In the control group, the age was 43-74 years old, with an average age65.91±3.63, containing 36 males and 54 females, while in the study group, the age was 44-76 years old, with an average age 65.96±3.58, containing 35 males and 55 females. There exhibited no statistical significance in the general data. This study was permitted by the Medical Ethics Association of our hospital, and all patients provided informed consent.APE risk stratification criteria are [17] as follows: (1) high risk level: shock or systemic hypotension; (2) moderate risk level: no shock or systemic hypotension, but right ventricular insufficiency and/or myocardial injury; the main clinical manifestations of right ventricular insufficiency are abdominal distension, loss of appetite, nausea, vomiting, and fatigue dyspnea caused by liver stasis; (3) low risk level: there was neither shock nor right ventricular insufficiency or myocardial injury.Diagnostic criteria: to observe whether the echocardiographic signs of thrombus in the right atrium, right ventricle, pulmonary artery trunk, and bifurcation can be observed by echocardiography, whether the indirect signs of increased pulmonary artery pressure, decreased activity of right ventricular wall, and increased right cardiac load could be observed.Inclusion criteria: (1) APE was confirmed by pulmonary angiography or pulmonary CTA; (2) blood gas analysis indicated hypoxemia; plasma D-dimer was positive; APE was diagnosed according to its symptoms, signs, ultrasound, and laboratory examination.Exclusion criteria: patients with poor ultrasound window, thrombolysis taboo, and other heart and lung diseases.


## 2.2. Treatment Methods

All patients were examined by echocardiography: emergency echocardiographic examination was performed in all patients with echocardiographic diagnostic equipment (manufacturer: Philips; model: PHILIPSEPIQ7C/PHILIPSIE33). The examination included parasternal artery short-axis section, parasternal left ventricular long-axis section, parasternal four-chamber view, and apical four-chamber view. The transverse and anterior-posterior diameters of left ventricle and right ventricle at the end of diastole were measured. The transverse diameter of the right atrium, the transverse diameter of the left atrium and the anterior and posterior diameter of the left atrium at the end of systole, the width of the main pulmonary artery at the end of systole, the amplitude of motion of the anterior wall of the right ventricle, the posterior wall of the left ventricle, and the interventricular septum were compared, whether there are thrombus echo signs in the right atrium, right ventricle, pulmonary artery trunk, and bifurcation.


## 2.3. Observation Index

### 2.3.1. Echocardiographic Value

Left ventricular end-diastolic diameter (LVED), right ventricular end-diastolic diameter (RVED), and pulmonary artery systolic pressure (PASP) were calculated and evaluated by measuring right atrial pressure and maximum tricuspid regurgitation pressure difference. Patients were instructed to hold their breath, and S5-1 probe was used to measure left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular volume per stroke (LVSV), and left ventricular ejection fraction (LVEF) at apical four-chamber and two-chamber views by Simpson’s biplane method.


### 2.3.2. Mitral Annulus Displacement

The early diastolic posterior septal displacement (ESD) and the left ventricular lateral wall displacement (ELD) of early diastolic mitral annulus were measured automatically by taking two points at the beginning and end of early diastole on the motion curves of the two sites. Similarly, the late diastolic mitral annulus posterior septal displacement (ASD) and late diastolic left ventricular lateral wall displacement (ALD) were automatically measured on the motion curve at two points at the beginning and end of late diastole.


## 2.3.1. Echocardiographic Value

Left ventricular end-diastolic diameter (LVED), right ventricular end-diastolic diameter (RVED), and pulmonary artery systolic pressure (PASP) were calculated and evaluated by measuring right atrial pressure and maximum tricuspid regurgitation pressure difference. Patients were instructed to hold their breath, and S5-1 probe was used to measure left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular volume per stroke (LVSV), and left ventricular ejection fraction (LVEF) at apical four-chamber and two-chamber views by Simpson’s biplane method.


## 2.3.2. Mitral Annulus Displacement

The early diastolic posterior septal displacement (ESD) and the left ventricular lateral wall displacement (ELD) of early diastolic mitral annulus were measured automatically by taking two points at the beginning and end of early diastole on the motion curves of the two sites. Similarly, the late diastolic mitral annulus posterior septal displacement (ASD) and late diastolic left ventricular lateral wall displacement (ALD) were automatically measured on the motion curve at two points at the beginning and end of late diastole.


## 2.4. Statistical Analysis

The data of this study were analyzed by SPSS 26.0; the counting data were presented byn%. The chi-square partition method was employed for the pairwise comparison, and the measurement data of normal distribution was presented by (x¯±s). The comparison was assessed by independent sample T-test, the correlation of normal distribution data was analyzed by Pearson’s correlation analysis, and the correlation between skewed distribution data and grade data was analyzed by Spearman correlation analysis. The difference exhibited statistical significance (P<0.05).


## 3. Results

### 3.1. Comparison of Side Values of Echocardiography

First of all, we compared the side values of echocardiography. RVED/LVED and PASP in the study group were higher compared to those in the control group, while LVEDV, LVESV, LVSV, and LVEF in the study group were lower compared to those in the control group (P<0.05). All the data results are indicated in Table 1.Table 1
Comparison of echocardiographic side values (x¯±s).
GroupNRVED/LVEDPASP (mmHg)LVEDV (ml)LVESV (ml)LVSV (ml)LVEF (∗10-2)C group900.61±0.2115.34±2.4578.93±8.3154.83±3.6648.81±3.6668.81±6.34R group900.94±0.1262.91±4.5455.39±6.5332.19±2.1632.58±3.5465.39±2.14t12.94387.47721.13050.53830.2384.848P<0.01<0.01<0.01<0.01<0.01<0.01


### 3.2. Comparison of Echocardiographic Side Values in Patients with Different APE Risk Stratifications

Secondly, we compared the echocardiographic side values of patients with different APE risk stratifications: RVED/LVED, PASP:low‐riskgroup<medium‐riskgroup<high‐riskgroup; LVEDV, LVESV, LVSV, LVEF: low‐riskgroup>medium‐riskgroup>high‐riskgroup (P<0.05). All the data results are indicated in Table 2.Table 2
Comparison of echocardiographic side values in patients with different APE risk stratifications (x¯±s).
GroupNRVED/LVEDPASP (mmHg)LVEDV (ml)LVESV (ml)LVSV (ml)LVEF (∗10-2)Low-risk group300.72±0.1220.85±4.6668.39±7.9345.69±3.5642.49±6.3267.93±3.11Medium-risk group300.89±0.3354.81±3.7657.38±3.6736.91±5.3435.91±3.7766.83±3.12High-risk group391.15±0.3582.49±2.4649.91±3.6725.18±3.4224.92±2.5665.93±3.54F16.7022046.08291.502170.552120.6172.859P<0.01<0.01<0.01<0.01<0.01<0.01


### 3.3. Routine Echocardiographic Findings in Patients with APE

Then, we analyzed the routine echocardiographic findings of APE patients: M-type left ventricular wave group of PE indicated right ventricular enlargement and interventricular septum shifted to left ventricle; short-axis section of PE artery indicated thrombosis at the opening of right pulmonary artery (indicated by arrow); long-axis section of the left ventricle of PE indicated right ventricular enlargement (RV 3.5 cm, LV 3.9 cm); four-chamber central section of PE indicated enlargement of right atrium and right ventricle, and interventricular septum shifted like left ventricle (Figures1(a)–1(d)).Figure 1
Routine echocardiographic findings in patients with APE.
(a)(b)(c)(d)


### 3.4. Comparison of Mitral Annulus Displacement between Control and Study Groups

Next, we compared the mitral annulus displacement. Compared to the normal control group, the early diastolic ESD and ELD in the study group were lower, while the late diastolic ASD and ALD in the study group were higher (P<0.05). See Table 3 and Figures 2 and 3 for details.Table 3
Comparison of mitral annulus displacement (x¯±s).
GroupNESD (mm)ASD (mm)ELD (mm)ALD (mm)C group906.25±1.234.59±1.068.39±1.214.06±1.21R group903.61±2.315.12±1.214.72±1.564.92±0.34t9.5693.12517.6356.491P<0.01<0.01<0.01<0.01Figure 2
Average displacement curve of mitral annulus in the normal group.Figure 3
Average displacement curve of mitral annulus in the APE group.


### 3.5. Analysis of the Relationship between Different APE Risk Stratifications and Left Ventricular Diastolic Function

Finally, we analyzed the correlation between different APE risk stratifications and left ventricular diastolic function. The results of Pearson’s correlation analysis indicated that RVED/LVED, PASP, and APE risk stratification were positively correlated, while LVEDV, LVESV, LVSV, and LVEF APE risk stratification were negatively correlated (P<0.05). All the data results are indicated in Table 4.Table 4
Analysis of the relationship between different APE risk stratifications and left ventricular diastolic function.
VariablerPRVED/LVED0.821<0.05PASP0.783<0.05LVEDV-0.685<0.05LVESV-0.575<0.05LVSV-0.377<0.05LVEFAPE-0.812<0.05


## 3.1. Comparison of Side Values of Echocardiography

First of all, we compared the side values of echocardiography. RVED/LVED and PASP in the study group were higher compared to those in the control group, while LVEDV, LVESV, LVSV, and LVEF in the study group were lower compared to those in the control group (P<0.05). All the data results are indicated in Table 1.Table 1
Comparison of echocardiographic side values (x¯±s).
GroupNRVED/LVEDPASP (mmHg)LVEDV (ml)LVESV (ml)LVSV (ml)LVEF (∗10-2)C group900.61±0.2115.34±2.4578.93±8.3154.83±3.6648.81±3.6668.81±6.34R group900.94±0.1262.91±4.5455.39±6.5332.19±2.1632.58±3.5465.39±2.14t12.94387.47721.13050.53830.2384.848P<0.01<0.01<0.01<0.01<0.01<0.01


## 3.2. Comparison of Echocardiographic Side Values in Patients with Different APE Risk Stratifications

Secondly, we compared the echocardiographic side values of patients with different APE risk stratifications: RVED/LVED, PASP:low‐riskgroup<medium‐riskgroup<high‐riskgroup; LVEDV, LVESV, LVSV, LVEF: low‐riskgroup>medium‐riskgroup>high‐riskgroup (P<0.05). All the data results are indicated in Table 2.Table 2
Comparison of echocardiographic side values in patients with different APE risk stratifications (x¯±s).
GroupNRVED/LVEDPASP (mmHg)LVEDV (ml)LVESV (ml)LVSV (ml)LVEF (∗10-2)Low-risk group300.72±0.1220.85±4.6668.39±7.9345.69±3.5642.49±6.3267.93±3.11Medium-risk group300.89±0.3354.81±3.7657.38±3.6736.91±5.3435.91±3.7766.83±3.12High-risk group391.15±0.3582.49±2.4649.91±3.6725.18±3.4224.92±2.5665.93±3.54F16.7022046.08291.502170.552120.6172.859P<0.01<0.01<0.01<0.01<0.01<0.01


## 3.3. Routine Echocardiographic Findings in Patients with APE

Then, we analyzed the routine echocardiographic findings of APE patients: M-type left ventricular wave group of PE indicated right ventricular enlargement and interventricular septum shifted to left ventricle; short-axis section of PE artery indicated thrombosis at the opening of right pulmonary artery (indicated by arrow); long-axis section of the left ventricle of PE indicated right ventricular enlargement (RV 3.5 cm, LV 3.9 cm); four-chamber central section of PE indicated enlargement of right atrium and right ventricle, and interventricular septum shifted like left ventricle (Figures1(a)–1(d)).Figure 1
Routine echocardiographic findings in patients with APE.
(a)(b)(c)(d)


## 3.4. Comparison of Mitral Annulus Displacement between Control and Study Groups

Next, we compared the mitral annulus displacement. Compared to the normal control group, the early diastolic ESD and ELD in the study group were lower, while the late diastolic ASD and ALD in the study group were higher (P<0.05). See Table 3 and Figures 2 and 3 for details.Table 3
Comparison of mitral annulus displacement (x¯±s).
GroupNESD (mm)ASD (mm)ELD (mm)ALD (mm)C group906.25±1.234.59±1.068.39±1.214.06±1.21R group903.61±2.315.12±1.214.72±1.564.92±0.34t9.5693.12517.6356.491P<0.01<0.01<0.01<0.01Figure 2
Average displacement curve of mitral annulus in the normal group.Figure 3
Average displacement curve of mitral annulus in the APE group.


## 3.5. Analysis of the Relationship between Different APE Risk Stratifications and Left Ventricular Diastolic Function

Finally, we analyzed the correlation between different APE risk stratifications and left ventricular diastolic function. The results of Pearson’s correlation analysis indicated that RVED/LVED, PASP, and APE risk stratification were positively correlated, while LVEDV, LVESV, LVSV, and LVEF APE risk stratification were negatively correlated (P<0.05). All the data results are indicated in Table 4.Table 4
Analysis of the relationship between different APE risk stratifications and left ventricular diastolic function.
VariablerPRVED/LVED0.821<0.05PASP0.783<0.05LVEDV-0.685<0.05LVESV-0.575<0.05LVSV-0.377<0.05LVEFAPE-0.812<0.05


## 4. Discussion

PE is a pathophysiological syndrome characterized by endogenous or exogenous emboli blocking pulmonary vessels, causing pulmonary circulation disturbance, progressive right heart failure, dyspnea, chest pain, hypotension, and other clinical manifestations [16]. APE leads to pulmonary vascular obstruction and blood flow reduction or interruption, resulting in varying degrees of hemodynamics and gas exchange disorders [17]. Mild cases have no obvious symptoms, and severe cases bring about a sharp increase in pulmonary vascular resistance due to PE, resulting in pulmonary hypertension, followed by right heart failure, which is an important factor leading to death [18]. The embolus fell off into the right cardiac system to embolize the pulmonary vessels, resulting in a decrease in the cross-sectional area of the pulmonary vascular bed and a gradual increase in pulmonary vascular resistance. The pulmonary vascular bed has a better compensatory capacity, and it will not cause an increase in pulmonary artery pressure when the embolic area is less than 30%, but when the embolic area is too large and the cross-sectional area of the pulmonary vascular bed is reduced by more than 30% to 50%, it will lead to an increase in pulmonary artery pressure [19]. The right ventricle is compensated by the Frank-Starling mechanism. Meanwhile, the activation of the neuroendocrine system further enhances the right ventricular contractility and maintains the right ventricular output. However, the compensatory capacity of the right ventricle to the pressure load is limited, with the increase of pulmonary artery pressure. The right ventricle is decompensated, the right ventricle is enlarged, and the myocardium is damaged, which finally leads to right heart failure. Right heart failure leads to the decrease of right ventricular output, the enlargement of right ventricle, and the increase of right ventricular wall tension, which makes the relative blood supply of right coronary artery insufficient, which can lead to myocardial ischemia and aggravate right cardiac insufficiency. The enlargement of the right ventricle shifts the interventricular septum to the left and limits left ventricular filling, resulting in a decrease in left ventricular preload. Meanwhile, pulmonary embolization can induce the release of neurohumoral vasoconstrictor factor and increase peripheral vascular resistance, resulting in increased left ventricular afterload; APE leads to pulmonary circulation obstruction, gas exchange disturbance, myocardial hypoxia, and decreased contractile force. Finally, the combined action of these factors leads to a decrease in left ventricular output, cardiogenic shock, and even death [20].APE is not a common cardiopulmonary disease; the condition is complex and lacks specific symptoms, so it is easy to miss diagnosis, have misdiagnosis, and have high mortality [21]. APE often causes changes in cardiac function, and the related mechanism is that pulmonary artery vessels are blocked by emboli, and changes in nervous and humoral factors lead to pulmonary artery spasm, increased pulmonary vascular resistance, and corresponding increased pulmonary artery pressure, while the increase of pulmonary artery pressure will aggravate the right ventricular afterload and cause right ventricular compensatory response [22]. When the increase of right ventricular load exceeds the right ventricular compensatory function, it can bring about pulmonary heart disease and make the right heart hypertrophy. The displacement of interventricular septum indirectly results in damage of left ventricular function, decrease of cardiac output, decrease of systemic blood flow, hypotension, and other symptoms even shock [23].Therefore, accurate evaluation of cardiac function in patients with APE is particularly important to judge the condition and prognosis [24]. APE can affect left ventricular function through a variety of mechanisms: (1) interventricular interdependence is the main factor affecting left ventricular function, the movement of one ventricle can directly affect the adjacent ventricle, and the enlargement of the right ventricle shifts the interventricular septum to the left ventricle and reduces left ventricular diastolic compliance, thereby reducing left ventricular output; (2) pericardial restriction, acute right ventricular dilatation, and unsynchronously dilated pericardium limit left ventricular diastolic filling; (3) acute right heart failure leads to a decrease in right ventricular output, thus reducing left ventricular preload, according to the Frank-Starling principle, left ventricular output is reduced [25]. In the United States, about 150 thousand patients are diagnosed with APE every year. Patients with normal blood pressure without right ventricular dysfunction have a mortality rate of about 2%, but patients with cardiogenic shock have a mortality rate of about 30%. The mortality rate of patients with cardiac arrest is as high as 65% [26]. Mechanical resistance of thrombus, pulmonary artery contraction stimulated by neurohumoral factors, and hypoxemia all caused an increase in pulmonary vascular resistance, an increase in right ventricular afterload, and a decrease in right ventricular output due to right ventricular enlargement and dysfunction, resulting in a decrease in left ventricular preload and left ventricular output [27]. If patients develop rapidly systemic arterial hypotension, cardiogenic shock may occur, and cardiac arrest and death may be fatal progression of PE. Therefore, hemodynamic instability is the main index of early death risk of PE, and congestive heart failure is an important index affecting the prognosis.The clinical symptoms of APE are diverse and lack specificity, ranging from occult, hemoptysis, chest pain, dyspnea, to hemodynamic instability and even syncope at first onset in some patients [28]. The clinical manifestation mainly depends on the location of PE and whether it is complicated with cardiopulmonary and other basic diseases. Chest pain is the most common clinical manifestation in patients with APE. It is mainly caused by pulmonary infarction caused by distal pulmonary vascular embolism, adjacent pleural irritation sign, or typical angina pectoris caused by myocardial damage caused by pulmonary artery embolism, which is easy to be confused with acute coronary syndrome, aortic dissection, and other diseases [29]. Dyspnea is more common in acute main PE, while in small peripheral PE, it is characterized by transient, mild to moderate dyspnea. For patients with previous lung disease or heart failure, severe dyspnea may be the only single clinical manifestation. A small number of patients with the first manifestation is dangerous; the mortality rate is high. Clinically, patients suspected of APE adopt a simple and easy “three-step” diagnosis strategy, emphasizing early risk stratification, gradual examination and clear diagnosis, and timely intervention treatment [30]. The prognosis of APE is closely related to the degree of embolism. In order to take appropriate drugs and interventional treatment for patients with APE, it is necessary to redefine the clinical subtypes of APE. According to its clinical manifestations and whether it is complicated with left ventricular diastolic dysfunction and circulatory failure, the American Heart Association divides PE into large area PE, sublarge area PE, and low-risk PE [31]. Left ventricular diastolic function is an important basis for APE diagnosis, risk stratification, and prognosis evaluation.Imaging examination is an important way to evaluate the changes of left ventricular function [32]. Compared with the right ventricle, the shape of the left ventricle is relatively regular and the structure is relatively simple, so it is more intuitive to assess the accurate shape and function of the left ventricle. Left ventricular catheterization is the gold standard for the evaluation of left cardiac hemodynamics, which can accurately reflect the changes of left ventricular pressure and evaluate the changes of left ventricular function, but because it is an invasive operation, left ventricular catheterization is not included as a routine examination item in clinic. CT pulmonary angiography (CTPA) is the first choice for the diagnosis of APE, which can directly show the location and extent of embolism and evaluate the severity of PE, but its application value is limited for patients with critical condition and hypersensitivity to contrast media [33]. The ratio of right ventricular to left ventricular maximum transverse diameter measured by CT is a common index to evaluate the left ventricular function of APE. It is closely related to the severity of APE; however, the sensitivity is poor. Magnetic resonance pulmonary angiography (MRPA) can clearly show the low-perfusion area of PE and evaluate the changes of left ventricular function with high tissue resolution [34]. MRPA is suitable for patients with iodine allergy, but the clinical application is limited because of long-time image acquisition, high imaging conditions, high price, complex operation, and limited clinical application. Echocardiography plays an important role in APE diagnosis, prognosis evaluation, and exclusion of other cardiovascular diseases. For clinically suspected APE patients, echocardiographic findings of thrombus in the left cardiac cavity and proximal pulmonary artery trunk can be clearly diagnosed [35]. Although echocardiography has some limitations in the display of direct signs of PE and the positive rate is low, it is often employed in clinical diagnosis and differential diagnosis of suspected APE because of its noninvasive, convenient operation and low price. Most of the indirect signs of APE are left ventricular overload, and the main manifestation is left ventricular dysfunction. The traditional two-dimensional echocardiography is still the most convenient method to detect ventricular function measuring the data such as LVEF, LVEDV, and LVESV [34, 35]. At present, the reports on the application of echocardiography in patients with APE focus on the evaluation of right ventricular function, while the research on left ventricular function in APE is rare. Doppler echocardiography is safe, noninvasive, simple, and repeatable. It is an important method to evaluate left ventricular function and predict the risk of prognosis in patients with PE. Echocardiography is an important method to evaluate left ventricular function, which has been widely employed in risk stratification, clinical management, and prognosis evaluation of APE. In particular, for patients with suspected PE and hemodynamic instability, echocardiographic detection of specific changes in pulmonary hemodynamics and left ventricular function is helpful for early clinical diagnosis and risk stratification [35]. For patients with stable hemodynamics, echocardiography can sensitively reflect the changes of left ventricular function and provide an important reference for the prognosis evaluation of APE.The results of this study indicated that compared with the control group, RVED/LVED and PASP in the study group increased remarkably, while LVEF, LVEDV, and LVESV decreased significantly, suggesting that there was damage to left ventricular function in patients with APE [36]. The two-dimensional gray-scale dynamic images of apical two-chamber view, four-chamber view, and apical long-axis view obtained by two-dimensional echocardiography can be used to measure related indexes and provide rich left ventricular work information. LVEF is an important index to reflect the left ventricular systolic function. The value of LVEF measured by echocardiography is consistent with that of cardiac MRI. In this study, the LVEF of the study group is lower compared to that of the control group, which is consistent with the relevant reports. Some scholars have indicated that the value of LVEF of the study group is remarkably lower compared to that of the control group, which is different from the results of this study and may be related to different research objects [35, 36]. This study also indicated that with the increase of risk classification, RVED/LVED and PASP increased, while LVEDV and LVESV decreased, suggesting that echocardiography attaches importance to evaluating the condition of patients with APE. For the patients whose RVED/LVED and PASP are remarkably increased and LVEDV and LVESV are remarkably decreased, even if the risk degree of the current patients is low, we should be vigilant against the risk of serious development of the disease and timely do the corresponding preparatory work and preventive measures to avoid the occurrence of poor prognosis. ASD and ALD indicated that the late diastolic mitral annulus contracted along the long axis to the left atrium, making the mitral annulus farther away from the apical. Our results indicated that compared to the normal control group, the early diastolic mitral annulus displacement and left ventricular diastolic function in the study group were lower, which may be caused by the decrease of left ventricular output and systemic perfusion, which led to the decrease of coronary artery perfusion and myocardial ischemia. Early affect left ventricular diastolic function. The late diastolic mitral annulus displacement was higher compared to that of the normal control group without the statistical significance. The possible mechanism is that the late diastolic mitral annulus movement depends on the contraction of the left atrium, the left ventricular output decreases, and the left atrial active contractility is strengthened, compensatory increase of left ventricular output, but it has been reported that the late diastolic movement of mitral annulus is mainly lateral rather than longitudinal. Echocardiography has the advantages of simplicity and intuition; it can evaluate the overall left ventricular diastolic and systolic function and can analyze a certain apical section when time is tight, which is beneficial to quickly assess the left ventricular diastolic function in patients with PE.In summary, echocardiography is of great significance in the evaluation of left ventricular diastolic function in APE. The side value of echocardiography can sensitively reflect the changes of left ventricular diastolic function in APE, and its predictive value in the diagnosis of APE is better than other traditional parameters of left ventricular diastolic function, especially in patients with different APE risk stratifications. There is a remarkable correlation between the changes of left ventricular diastolic function and different APE risk stratifications. Echocardiographic measurement is simple and can be employed to evaluate left ventricular diastolic function in APE, which can be developed in clinical treatment and prognosis evaluation to provide a new evaluation approach.



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*Source: 3483390-2022-05-11.xml*