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

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Presentation on theme: "Echocardiography in the clinical situation: what can we do with it? LHB Baur, MD,PhD."— Presentation transcript:

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 % 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

24

25 Aortic valve stenosis

26 Hypertrofic cardiomyopathy

27 Pericarditis

28 Mitral valve prolapse

29 Aortic Dissection

30 Relation between extent of infarction and thickening Systolic thickening (%) 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 LADRCARCX Ant2222 Inf3338 Post lat147 Agreement 62/82 = 76%

33 Infarct Location: the ECHO Angio LADRCARCX Ant2141 Inf Post lat 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 5 no clinical MI 31 clinical MI 10 cardiac complications 3/3 had CAD on angiography 2 subendocardial infarction 27 no MI 29 no complications 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 3 (12%) no clinical MI 22 (88%) clinical MI 4 subendocardial infarction 14 no 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 Direct Hospital Admission 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/ % Gibler Ann Emerg. Med 1995; 25: 1-8

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

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

41 Advantages/Limitations Advantage: –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 < 30% % % % > 80% Ischemia Domain Echocardiographic Ejection Fraction (%) % 6-month mortality

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

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

65

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

75

76

77

78

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


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