From the Guidelines
Right atrial enlargement can be indicative of a pulmonary embolism, but it is not a specific or definitive sign. Pulmonary embolism can cause increased pressure in the pulmonary arteries, leading to right ventricular strain and, subsequently, right atrial enlargement. However, this finding is neither sensitive nor specific for pulmonary embolism. Many other conditions can cause right atrial enlargement, including chronic obstructive pulmonary disease, pulmonary hypertension, right-sided heart failure, and certain congenital heart defects.
Key Points to Consider
- In the context of suspected pulmonary embolism, right atrial enlargement should be considered alongside other clinical signs, symptoms, and diagnostic tests such as D-dimer levels, CT pulmonary angiography, or ventilation-perfusion scans 1.
- The absence of right atrial enlargement does not rule out pulmonary embolism, and its presence alone is insufficient to diagnose the condition.
- A comprehensive clinical evaluation and appropriate imaging studies are necessary for accurate diagnosis and management of pulmonary embolism.
- Echocardiography may suggest or reinforce clinical suspicion of PE if right ventricular (RV) overload and dysfunction is found in the presence of Doppler signs of increased pulmonary arterial pressure 1.
- A typical echocardiographic picture of haemodynamically significant PE includes dilated, hypokinetic RV, an increased RV/LV ratio caused by interventricular septal bulging into the LV, dilated proximal pulmonary arteries, increased velocity of the jet of tricuspid regurgitation, and disturbed flow velocity pattern in the RV outflow tract 1.
Diagnostic Approach
- Consider the clinical presentation and initial therapy aimed at life-saving restoration of flow through occluded pulmonary arteries or at the prevention of potentially fatal early recurrences 1.
- Use a combination of clinical signs, symptoms, and diagnostic tests to diagnose pulmonary embolism.
- Echocardiography and Doppler analysis of right heart dimensions and RV function can provide useful information, but are not definitive for diagnosis or exclusion of suspected PE 1.
From the Research
Right Atrial Enlargement and Pulmonary Embolism
- Right atrial (RA) enlargement can be associated with pulmonary embolism (PE), as seen in cases where a large free-floating right atrial mass is present 2.
- The presence of a right atrial thrombus is a rare entity frequently encountered in patients with pulmonary embolism, and is associated with worse outcomes 3.
- Mobile thrombus in the right cardiac chambers, including the right atrium, is a neglected cause of PE and poses an immediate risk to life 4.
- However, not all cases of right atrial enlargement are directly related to pulmonary embolism, as seen in a case of a giant right atrium in an adult without tricuspid stenosis or other common adult associations of RA abnormality, such as chronic pulmonary disease or pulmonary embolism 5.
Prognosis and Treatment
- The prognosis for patients with PE and right ventricular (RV) enlargement, but without shock, is generally good, with low in-hospital mortality rates 6.
- The presence of RA enlargement or thrombus may require aggressive treatment, particularly in patients with severe right ventricular dysfunction 3.
- The use of thrombolytic agents, surgical embolectomy, and other treatments may be considered on a case-by-case basis, depending on the severity of the condition and the presence of other risk factors 2, 3, 4.