1. Echocardiography in the clinical situation: what can we do with it?
LHB Baur, MD,PhD

2. The First Aid Department

3. Reasons for chest pain Acute myocardial infarction Unstable angina
Pericarditis
Dissection of the aorta
Syndrome X
Cholecystitis
Oesophagitis

4. More reasons: Aortic stenosis Hypertrophic cardiomyopathy
Mitral valve prolapse

5. Pathophysiology after coronary occlusion
1. Diastolic abnormalities (< seconds)
2. Systolic contractile dysfunction
3. EKG abnormalities

6. Diagnosis of myocardial infarction
Clinical history +
Electrocardiogram +
Enzymes

7. Regional Contractile Abnormalities
Reduced inward wall motion
Decreased wall thickening
Dyskinesis

8. Infarct location and coronary vessel involved
Agreement = 76%

9. Infarct location and coronary vessel involved
Agreement = 81%

10. The ECG
The diagnostic markers of injury are ABSENT in 50 % of patients with acute myocardial infarction

11. More data...
85 % of Emergency room patients presenting with chest pain do not have acute myocardial infarction
5% of those who do have an acute myocardial infarction are mistakenly discharged from the emergency room

12. Goals of echocardiographic evaluation in patients with suspected myocardial infarction
Diagnosis of acute myocardial infarction
Identification of the coronary vessel involved
Assessment of the area of myocardium at risk
Exclusion of other causes of chest pain
Evaluation of reperfusion therapy

13. Parasternal Long Axis

14. Parasternal short axis

15. Apical 4 Chamber

16. Apical 2 Chamber

17. 16-segment model for wall motion analysis

18. Arterial distribution (fig 10-2)

19. Inferior infarction

20. Anteroseptal infarction

21. 2 Chamber View

22. Long Axis

23. Short axis

25. Aortic valve stenosis

26. Hypertrofic cardiomyopathy

27. Pericarditis

28. Mitral valve prolapse

29. Aortic Dissection

30. Relation between extent of infarction and thickening40 30 20
Systolic thickening (%) 10
-10
-20
1-20
21-40
41-60
61-80
81-100
Infarct thickness (%)
Lieberman; Circ: 1981: 63: 739

31. Modes of echocardiography
TTE:wall motion, global LV-function, complications of myocardial infarction (VSR-mitral regurgitation)
TEE: myocardial rupture
Stress-echo: viability, recurrent ischemia
Contrast-echo: enhancement of tricuspid regurgitant jets

32. Infarct Location: the ECG
Angio
LAD
RCA
RCX
Ant 22 2 2
Inf 3 33 8
Post lat 1 4 7
Agreement 62/82 = 76%

33. Infarct Location: the ECHO
Angio
LAD
RCA
RCX
Ant 21 4 1
Inf 2 30 5
Post lat 2 10
Agreement 61/75 = 81%

34. Role in patient triage 80 patients admitted with chest pain 15
technically
difficult 36
abnormal
RWM
on echo 29
normal
RWM
on echo 2
subendocardial
infarction 27
no MI 31
clinical MI 5
no clinical MI 29 no
complications 10
cardiac
complications
3/3
had
CAD on
angiography
Horowitz Circ 1982; 65:

35. Echo in patient triage 43 patients admitted with chest pain 25
abnormal
RWM
on echo 18
normal
RWM
on echo 4
subendocardial
infarction 14
no MI
22 (88%)
clinical MI
3 (12%)
no clinical MI
CH Peels: Am J. Cardiol 1990: 65:

36. Echo in Myocardial Infarction

37. ECG in triage Diagnostic abnormalities in 30 %
Non specific abnormalities in 33 %
Normal in 10 %
Uninterpretable in 27 % because of BBB or paced rythm
Sabia Circ 1991;92: 84I-85I

38. Chest Pain evaluation unit
Symptoms of
acute ischemia
History of CAD
Hemodynamic instability
ST  or ST  > 1 mm
Unstable angina
Chest Pain Evaluation Unit
Serial CK-MB, Troponin
12 lead EKG
2D echo and exercise test at 9 h
Released home
829/1010 (82%)
Admitted for further
evaluation 153/1010
15%
Direct
Hospital
Admission
Gibler Ann Emerg. Med 1995; 25: 1-8

39. Myocardial Infarction
Treat for AMI or
unstable angina
Diagnostic
ECG
Chest Pain
Nondiagnostic
ECG 2D
Echo
Normal Wall motion
during chest pain
Normal Wall motion
in abscence of
chest pain
Regional Wall
motion abnormality
Acute or old
Myocardial Infarction
Outpatient
evaluation
Stress echo

40. Echocardiography in the CCU
Acute myocardial infarction
Detection of complications
Prognostic implications

41. Advantages/Limitations
portability
noninvasive
anatomic and hemodaynamic information
Limitations:
limited transthoracic windows
only qualitative analysis of regional wall motion abnormalities

42. Pathophysiology and echocardiographic correlations
Timing and evolution of infarction:
¯ systolic wall thickening; dyskinesia
Reperfusion ther., stunning, infarct size:
echo wall motion abnormalities is more accurate after permanent occlusion;
mostly overestimation of infarct size;
better after 2 weeks;
> 6 months: underestimation volume of necrosis

43. Infarct localization
LAD: anterior, anterolateral, anteroseptal and apical segments
LCX: lateral wall and lateral apex
RDP (80% RCA): inferolateral wall, inferior free wall, inferior septum and right ventricle

44. Mitral regurgitation
Incomplete coaptation due to papillary muscle ischemia
especially inferolateral or posteromedial (only RCA) papillary muscle
severe global LV-dysfunction (large anterior infarction)

45. Diagnosis and ealy risk stratification
Wall motion abnormalities, fals positive when:
WPW, LBBB, CABG (septum), RV-volume overload (septum)
Scoring system for grading wall motion

46. Prognosis EF and Mortality Viability Domain Ischemia Domain 20
< 30%
% 6-month mortality
Viability Domain 10 %
Ischemia Domain % %
> 80% 20 30 40 50 60 70
Echocardiographic Ejection Fraction (%)

47. Wall Motion Score LV wall motion and scoring . Scoring; = total score
LV wall motion score index
total score
Total scored segments

48. Scoring system for grading wall motion (table 10-1)

49. RV-infarction (table 10-3)

50. Complications detected by echo (table 10-4)

51. Mitral inflow Diastolic function and LV-filling pressures:
E/A ratio (early filling velocity/atrial filling velocity)
deceleration time of ealy filling
IVRT: isovolumetric relaxation time

52. LV-diastolic dysfunction
Impaired relaxation:
¯ E/A ratio
prolonged deceleration and isovolumetric relaxation time
Decreased compliance :
­ E/A ratio
shortened isovolumetric ralaxation and deceleration times

53. Pericarditis and pericardial effusion (18-44%)
3-10 days after Q-wave infarction
> 10 days: Dressler
larger infarctions have more pericardial effusion

54. Mitral regurgitation, 10-15% after AMI
Risk factors: aged, female, diabetes, prior infarction
Severe/moderate: reduced short- and long-term survival
Always echo when:
new systolic murmer
pulmonary edema
sudden cardiac decompensation

55. Mitral regurgitation - echo
2D: abnormalities in mitral valve apparatus
Color flow: grading
Doppler: flow velocity

56. Mitral valve incompetence

57. Ventricular septal rupture (VSR)
3-6 days after infarction (1%):
chest pain; dyspnea; hypotension/shock
pansystolic murmer
echo: sensitivity 86-90%
most common site: posteroapical sept. (parasternal short axis; apical 4-chamb)
increased RV-pressure

58. Apical VSR

59. Rupture of free wall and pseudoaneurysm (3%)
posterolateral wall (LCx)
echo:
pericardial effusion
thrombus in pericardial space
tamponade:
RA and RV diastolic collapse
respiratory variation of tricuspid and mitral inflow pattern

60. True and false aneurysm (fig 10-9)

61. LV-thrombus most common: left ventricular apex
large apical aneurysm, oral anticoagulation is recommended

62. Mural Thrombus

63. Resuscitation

64. Resuscitation

65. Resuscitation

66. Statements
Een echocardiogram toont endocarditis niet aan en sluit dit niet uit.
Echocardiografie is aanvullend onderzoek om
een vermoedelijke diagnose te bevestigen
de ernst van de (klep)aandoening vast te leggen
de hemodynamische consequenties vast te leggen

67. Sensitiviteit om klepvegetaties aan te tonen
641 pts (meta analyse)
M- Mode echocardiografie: 52%
2D echocardiografie: 79%
Vegetaties kleiner dan 3 mm kunnen niet worden aangetoond
O’Brien Am Heart J 1984

68. Sensitiviteit om klepvegetaties aan te tonen
Transoesafageale echocardiografie: 92%
Chest 1994; 105:

69. Voorspellen van Complicaties
Hogere kans op complicaties bij:
meer mobiele vegetaties
uitgebreidere vegetaties
grootte van de vegetaties
10 % bij 6 mm vegetaties
50 % bij 11 mm vegetaties
100 % bij 16 mm vegetaties

70. Complicaties zichtbaar met echo
Absces in de annulus
Fistels
Ernstige insufficientie
Paravalvulaire lekkage
Kunstklepdehiscentie
Kunstklep obstructie

71. Key Points
Echocardiografie heeft een centrale plaats bij de diagnostiek en behandeling van endocarditis
Alle patienten met endocarditis dienen seriele echocardiografische onderzoeken te ondergaan
De meeste patienten dienen op z’n minst een keer tijdens de ziekte een TEE onderzoek te ondergaan
Ervaren onderzoekers zijn essentieel

72. Endocarditis

73. Mitral Valve Vegetation

74. The Small Echo Machine

79. Stetoscope versus Echo
36 patients
cardiac exam followed by exam with small echo machine
79 cardiovascular findings
34 major cardiovascular abnormalities

80. Stetoscope versus Echo
Physical exam missed:
59% of the findings overall
45% of major findings
Portable echo machine reduced this percentage to:
29% overall
21% of major findings

81. Auscultation versus Echo

82. Echo is a Horse: Mostly a workhorse Sometimes a Lipizaner