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Echocardiography in the clinical situation: what can we do with it?

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Presentation on theme: "Echocardiography in the clinical situation: what can we do with it?"— 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... 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 thickening
40 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

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