Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist

Figures

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  Fig. 1. Right and left heart. Blue arrow demonstrates the right ventricle with a thin wall and crescent shape. Red arrow demonstrates the thicker wall of the left ventricle

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  Fig. 2. Right and left heart pressures. Diagram demonstrates the right (blue) and left (red) heart pressures

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  Fig. 3. Relationship of afterload and stroke volume. Right ventricular (red) stroke volume response to increases in afterload is devastating compared to the left ventricular (blue) stroke volume response which is more gradual

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  Fig. 4. Normal and abnormal appearance of right and left ventricles due to afterload. a Depicts normal systolic and diastolic appearance of the right and left ventricles. b Demonstrates a dilated right ventricle that impinges on the left ventricle due to increased afterload

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  Fig. 5. Pictorial depiction of the compromise of the coronary arteries. a Depicts uninhibited flow of blood through a coronary artery as it passes through the folds (arrow) of the right ventricular wall. b Depicts a coronary artery with region of stenosis due to straightening of the folds in a dilated RV wall

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  Fig. 6. Tricuspid regurgitation in a dilated right ventricle and right atrium. Fiesta cine sequence MRI image demonstrates a four-chamber view with incomplete closure of the tricuspid valve due to right ventricular dilatation resulting in tricuspid valve regurgitation (arrow)

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  Fig. 7. Hemodynamic collapse in PE. Diagram demonstrates a spiral resulting in hemodynamic collapse in patients with massive and submassive PE

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  Fig. 8. Depiction of the effects of preload on output from the RV to the pulmonary arteries. If preload is decreased due to venous dilation and pooling of the blood in the dilated venous system, there is decreased filling of the RV and decreased available volume for output

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  Fig. 9. Measurement of RV/LV ratio. Axial CT images demonstrate the best approximated four-chamber view. Calipers are placed from inner wall to inner wall at the maximal diameter on a view that best approximates the four-chamber view

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  Fig. 10. Treatment algorithm for acute PE. Diagram demonstrates an algorithm for treatment of acute PE

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  Fig. 11. A 44-year-old male with a left lower extremity DVT after trauma presenting with massive PE, 8 days after initiation of anticoagulation for the DVT. Patient was hypotensive with a BP of 78/45 and troponin I elevation of 0.83 ng/mL. a CTA demonstrates a saddle pulmonary embolus (white arrow) and increased RV/LV ratio with blue calipers demonstrating the diameter of the RV and the red calipers demonstrating the diameter of the LV. b Fluoroscopic images of aspiration thrombectomy. A 90 cm 8Fr Sheath (white arrow) through which is passed an Indigo CAT-8 thrombectomy device (black arrowhead, Indigo, Penumbra, Alameda, CA, USA). Black closed arrow demonstrates a safety wire to stabilize access to the left pulmonary artery. Black open arrow demonstrates the Indigo separator to clear thrombus from the opening of the catheter. c Pulmonary angiogram demonstrates before and after catheter-directed therapy pictures. Arrow demonstrates improved perfusion to the lower lobe. d CTA demonstrates before and after catheter-directed therapy images with improvement in thrombus burden and before and after catheter-directed therapy images with improvement in RV/LV ratio

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  Fig. 12. A 63-year-old man with renal cell carcinoma and hemorrhagic brain metastases presenting with submassive PE, felt not safe for anticoagulation. The patient was normotensive but had decreased RV motility on Echocardiogram, pro-BNP of 930 pg/mL, and troponin I elevation of 0.46 ng/mL, and ECG changes. a ECG in a patient with submassive PE depicts ischemia demonstrates inverted T waves in V1–V4 leads, a representative ECG abnormality that may be seen with submassive PE. b CTA demonstrates right main pulmonary artery and lobar pulmonary emboli (white arrows). c CTA demonstrates increased RV/LV ratio with blue calipers measuring the RV and red calipers measuring the left ventricle. d Before and after mechanical thrombectomy pulmonary angiogram images depicting improved patency of the right main pulmonary artery (solid arrow) and perfusion to the right lower lobe (open arrow) compared to before