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Echocardiography in the clinical situation: what can we do with it?. LHB Baur, MD,PhD. The First Aid Department. Reasons for chest pain. Acute myocardial infarction Unstable angina Pericarditis Dissection of the aorta Syndrome X Cholecystitis Oesophagitis. More reasons:. - PowerPoint PPT Presentation
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Echocardiography in the clinical situation: what can we do with it?
LHB Baur, MD,PhD
The First Aid Department
Reasons for chest pain
• Acute myocardial infarction• Unstable angina• Pericarditis• Dissection of the aorta• Syndrome X• Cholecystitis• Oesophagitis
More reasons:
• Aortic stenosis• Hypertrophic cardiomyopathy• Mitral valve prolapse
Pathophysiology after coronary occlusion
• 1. Diastolic abnormalities (< seconds)• 2. Systolic contractile dysfunction• 3. EKG abnormalities
Diagnosis of myocardial infarction
• Clinical history +• Electrocardiogram +• Enzymes
Regional Contractile Abnormalities
• Reduced inward wall motion• Decreased wall thickening• Dyskinesis
Infarct location and coronary vessel involved
Infarct Location (Angio)LAD RDP RCX
Anterior 22 2 2Inferior 3 33 8
EKG
Postero-lateral
1 4 7
Agreement = 76%
Infarct location and coronary vessel involved
Infarct Location (Angio)LAD RDP RCX
Anterior 21 4 1Inferior 2 30 5
ECHO
Postero-lateral
0 2 10
Agreement = 81%
The ECG
• The diagnostic markers of injury are ABSENT in 50 % of patients with acute myocardial infarction
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
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
Parasternal Long Axis
Parasternal short axis
Apical 4 Chamber
Apical 2 Chamber
16-segment model for wall motion analysis
Arterial distribution (fig 10-2)
Inferior infarction
Anteroseptal infarction
2 Chamber View
Long Axis
Short axis
Aortic valve stenosis
Hypertrofic cardiomyopathy
Pericarditis
Mitral valve prolapse
Aortic Dissection
Relation between extent of infarction and thickening
-20
-10
0
10
20
30
40
Syst
olic
thic
keni
ng (%
)
0 1-20 21-40 41-60 61-80 81-100
Infarct thickness (%)Lieberman; Circ: 1981: 63: 739
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
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%
Infarct Location: the ECHO
Angio
LAD RCA RCX
Ant 21 4 1
Inf 2 30 5
Post lat 0 2 10
Agreement 61/75 = 81%
Role in patient triage80 patients admitted with chest pain
15technically
difficult
36abnormal
RWMon echo
29normalRWM
on echo
5 no clinical
MI
31clinical
MI
10cardiac
complications
3/3hadCADon
angiography
2subendocardial
infarction
27no MI
29no
complications
Horowitz Circ 1982; 65: 323-329
Echo in patient triage43 patients admitted with chest pain
25abnormal
RWMon echo
18normalRWM
on echo
3 (12%) no clinical
MI
22 (88%)clinical
MI
4subendocardial
infarction
14no MI
CH Peels: Am J. Cardiol 1990: 65: 687-691
Echo in Myocardial Infarction
First Author n sensitivity specificity
Horowitz 80 84 84
Nishimura 61
Peels 43 92 53
Sabia 180 90 53
Saeian 60 88 94
Gibler 901 47 99
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
Chest Pain evaluation unitSymptoms of
acute ischemia
History of CADHemodynamic instabilityST or ST > 1 mmUnstable angina
Direct HospitalAdmission
Chest Pain Evaluation UnitSerial CK-MB, Troponin12 lead EKG2D echo and exercise test at 9 h
Released home829/1010 (82%)
Admitted for furtherevaluation 153/101015%
Gibler Ann Emerg. Med 1995; 25: 1-8
Chest Pain
2DEcho
NondiagnosticECG
Treat for AMI orunstable anginaDiagnostic
ECG
Normal Wall motionduring chest pain
Normal Wall motionin abscence of
chest pain
Regional Wallmotion abnormality
Outpatientevaluation
Stress echo Acute or oldMyocardial Infarction
Echocardiography in the CCU
Acute myocardial infarctionDetection of complications
Prognostic implications
Advantages/Limitations
• Advantage:– portability– noninvasive– anatomic and hemodaynamic information
• Limitations:– limited transthoracic windows– only qualitative analysis of regional wall
motion abnormalities
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
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
Mitral regurgitation
Incomplete coaptation due to papillary muscle ischemia– especially inferolateral or posteromedial
(only RCA) papillary muscle– severe global LV-dysfunction (large
anterior infarction)
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
PrognosisEF and Mortality
Viability DomainViability Domain
< 30%< 30%
30 - 39%30 - 39%
40 - 49%40 - 49% 50 - 59%50 - 59% > 80%> 80%
Ischemia DomainIschemia Domain
Echocardiographic Ejection Fraction (%)Echocardiographic Ejection Fraction (%)
% 6-month% 6-monthmortalitymortality
2020 3030 4040 5050 6060 707000
1010
2020
Wall Motion Score
LV wall motion and scoring .
Scoring;
= total scoreTotal scored segments
LV wall motion score index
Scoring system for grading wall motion (table 10-1)
RV-infarction (table 10-3)
Complications detected by echo (table 10-4)
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
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
Pericarditis and pericardial effusion (18-44%)
• 3-10 days after Q-wave infarction• > 10 days: Dressler• larger infarctions have more pericardial
effusion
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
Mitral regurgitation - echo
• 2D: abnormalities in mitral valve apparatus
• Color flow: grading• Doppler: flow velocity
Mitral valve incompetence
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
Apical VSR
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
True and false aneurysm(fig 10-9)
LV-thrombus
• most common: left ventricular apex• large apical aneurysm, oral
anticoagulation is recommended
Mural Thrombus
Resuscitation
Resuscitation
Resuscitation
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
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
Sensitiviteit om klepvegetaties aan te tonen
• Transoesafageale echocardiografie:92%
Chest 1994; 105: 377-382
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
Complicaties zichtbaar met echo
• Absces in de annulus• Fistels• Ernstige insufficientie• Paravalvulaire lekkage• Kunstklepdehiscentie• Kunstklep obstructie
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
Endocarditis
Mitral Valve Vegetation
The Small Echo Machine
Stetoscope versus Echo
• 36 patients• cardiac exam followed by exam with
small echo machine• 79 cardiovascular findings• 34 major cardiovascular abnormalities
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
Auscultation versus Echo
echocardiogram
normal abnormal
normal 42 0
ausc
ulta
tion
abnormal 21 9
Echo is a Horse:Mostly a workhorse
Sometimes a Lipizaner