EMERGENCY ECHOCARDIOGRAPHY

Dr Alistair Cormack ST6 Cardiology Stirling Royal Infirmary

Indications for emergency echocardiography

Pulmonary thromboembolsim (PTE) with haemodynamic/respiratory compromise

Pericardial effusion with tamponade

Aortic dissection

Complications of acute myocardial infarction

Peri-arrest

Pulmonary thromboembolism

Presentation Chest pain

Usually pleuritic, occasionally anginal (RV ischaemia)

Dyspnoea Sudden onset

Collapse Hypotension, tachycardia

Associated features Swollen leg, recent long-distance travel, recent

surgery, malignancy, immobility

Pulmonary thrombolembolism

Clinically Hypotensive

Tachycardica

Dyspnoiec

Hypoxic

Raised JVP

Clear chest

ECG Sinus tachycardia most common

RBBB, AF, S1Q111T111 patterns possible

Pulmonary thrombolembolism

Clinically Hypotensive Tachycardica Dyspnoiec Hypoxic Raised JVP Clear chest

ECG Sinus tachycardia most common RBBB, AF, S1Q111T111 patterns possible

CXR typically normal

Pulmonary Embolism Management

Non-massive

Heparinisation and warfarinisation

Massive

Systolic BP <90mmHg/40mmHg drop in 15 minutes

Massive Pulmonary Embolism

Management

Thrombolysis

Embolectomy

Catheter fragmentation

All high risk

Massive Pulmonary embolism

CTPA is diagnostic modality of choice

Massive Pulmonary embolism

CTPA is diagnostic modality of choice

Echocardiography if CT unavailable

No available, convenient CT

Patient too unstable

Echo must support clinical diagnosis of PTE to consider high risk treatment options

Echo features of acute PTE

Thrombus in transit

Copyright restrictions may apply.

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Thrombus visualization by echocardiography

Echo features of acute PTE

Thrombus in transit

Unusual

Acute right ventricular overload/strain

RV dilatation

Reduced RV systolic function

McConnell’s (hinge) sign Relative sparing of RV apex

Echo features of acute PTE

Thrombus in transit

Unusual

Acute right ventricular overload/strain

RV dilatation

Reduced RV systolic function

McConnell’s (hinge) sign Relative sparing of RV apex

Abnormal RV outflow (60/60 sign)

RVOT acceleration time >60ms if PASP <60mmHg

Copyright restrictions may apply.

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Initial risk stratification of patients with suspicion of PE

Copyright restrictions may apply.

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Diagnostic algorithm for high-risk patients with suspicion of PE

Pericardial Effusion

Aetiology

Pericarditis

Viral

Idiopathic

Inflammatory

Malignant

Iatrogenic

Traumatic

Pericardial Effusion with Tamponade

Occurs when increased pericardial pressure exceeds right atrial (and thus right ventricular end diastolic pressure)

Clinically

Hypotensive

Raised JVP

Peripheral oedema

Clear chest

Pulsus paradoxus

Pericardial effusion with tamponade

ECG – small copmlexes

CXR – enlarged cardiac silhouette

Pulsus paradoxus in pericardial effusion

Drop of systolic BP by 10mmHg with normal inspiration

Inspiration lowers thoracic BP, improving venous return

Increased RV filling impinges on LV performance

(also found in severe asthma, RV infarct, severe PTE etc.)

Echo findings in tamponade

Pericardial effusion

May be minimal in ‘surgical’ cases

Signs of impaired right sided performance

RA diastolic collapse

RV diastolic collapse

Echocardiographical ‘pulsus paradoxus’

MV inflow velocities drop by 25% with normal inspiration

Echo in tamponade

Assess routes of tamponade relief

Percutaneous approach

Subxiphisternal most common

Apically

Surgical

Posterior

Intervening structures e.g. Massive hepatomegaly

Pericardial tamponade

Management

Drainage

Percutaneous

Surgical

Percutaneous

Fluoroscopy guided

Echo guided

Injection of agitated saline into Cook’s needle

Aortic dissection

Intimal flap of aorta

May involve any part of aorta

Ascending dissections managed surgically

Descending dissections managed medically

Definitive diagnosis usually made by CT scanning though TOE reported to have similar sensitivity and specificity

Transthoracic echo in aortic dissection

Only 70% sensitive

Close to 100% sensitive for life threatening complications

Aortic incompetence

Pericardial effusion

Left ventricular wall motion abnormality if coronary involvement

Catastrophic complications of myocardial infarction

Ventricular free wall rupture

Ventricular septal defect

Acute mitral incompetence

Increasingly rare

Usually after transmural infarcts not receiving timely reperfusion therapy

Mitral Regurgitation in Myocardial Infarction

Relatively common

Usually due to wall motion abnormality involving papillary muscle, typically inferior, posterior or lateral myocardial infarction

Infrequently due to LV and subsequently mitral annular dilatation

Rarely, though catastrophically due to flail mitral valve Ruptured papillary muscle head

Ruptured chordae

Flail mitral valve

Severe mitral regurgitation Murmur may be unimpressive

High left atrial pressure

Associated with haemodynamic collapse and pulmonary oedema

Severe mitral regurgitation Hyperdynamic left ventricle

Regional wall motion abnormality subtending papillary muscle

Valve leaflet may prolapse into left atrium May see mass ‘flail’ into left atrium Typically non-dilated left atrium

Flail mitral valve

Management

Intra-aortic balloon pump

Coronary arteriography

Emergency surgery – usually mitral valve replacement and CABG

High mortality with medical management

Acute ventricular septal defect Following septal myocardial infarction,

usually trans-mural

Muscular septum

Loud systolic murmur

Acute cardiovascular collapse

Acute VSD

Echocardiography demonstrates left ventricular to right ventricular colour flow

Assiciated peri-defect wall motion abnormality

Needs repaired even if no haemodynamic compromise as usually grows

Open surgery vs device closure

Attempt to size defect

Cardiac Rupture

Typically following transmural infarct with no reperfusion therapy

Emptying of left ventricular contents into pericardial sac

Rapid deterioration and death from cardiac tamponade

Cardiac rupture

Pseudoaneurysm

Pericardial effusion

Acute angle of neck of communication

Cf obtuse angle in true aneurysm

Colour flow from LV to pericardium

Wall motion abnormality either side of defect

Management is immediate surgery

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Periarrest echo

Cardiac tamponade

Massive pulmonary embolism

Severe left ventricular systolic dysfunction