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

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

• LHB Baur, MD,PhD

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The First Aid Department
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Reasons for chest pain

• Acute myocardial infarction
• Unstable angina
• Pericarditis
• Dissection of the aorta
• Syndrome X
• Cholecystitis
• Oesophagitis

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More reasons

• Aortic stenosis
• Hypertrophic cardiomyopathy
• Mitral valve prolapse

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Pathophysiology after coronary occlusion

• 1. Diastolic abnormalities (lt seconds)
• 2. Systolic contractile dysfunction
• 3. EKG abnormalities

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Diagnosis of myocardial infarction

• Clinical history
• Electrocardiogram
• Enzymes

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Regional Contractile Abnormalities

• Reduced inward wall motion
• Decreased wall thickening
• Dyskinesis

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Infarct location and coronary vessel involved
Agreement 76
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Infarct location and coronary vessel involved
Agreement 81
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The ECG

• The diagnostic markers of injury are ABSENT in 50
  of patients with acute myocardial infarction

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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

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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

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Parasternal Long Axis
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Parasternal short axis
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Apical 4 Chamber
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Apical 2 Chamber
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16-segment model for wall motion analysis
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Arterial distribution (fig 10-2)
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Inferior infarction
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Anteroseptal infarction
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2 Chamber View
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Long Axis
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Short axis
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Aortic valve stenosis
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Hypertrofic cardiomyopathy
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Pericarditis
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Mitral valve prolapse
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Aortic Dissection
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Relation between extent of infarction and
thickening
40
30
20
10
Systolic thickening ()
0
-10
-20
0
1-20
21-40
41-60
61-80
81-100
Infarct thickness ()
Lieberman Circ 1981 63 739
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Modes of echocardiography

• TTEwall 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

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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
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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
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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
5 no clinical MI
31 clinical MI
29 no complications
10 cardiac complications
3/3 had CAD on angiography
Horowitz Circ 1982 65 323-329
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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
3 (12) no clinical MI
22 (88) clinical MI
CH Peels Am J. Cardiol 1990 65 687-691
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Echo in Myocardial Infarction
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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 199192 84I-85I
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Chest Pain evaluation unit
Symptoms of acute ischemia
History of CAD Hemodynamic instability ST ? or ST
? gt 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
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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
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Echocardiography in the CCU

• Acute myocardial infarction
• Detection of complications
• Prognostic implications

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Advantages/Limitations

• Advantage
• portability
• noninvasive
• anatomic and hemodaynamic information
• Limitations
• limited transthoracic windows
• only qualitative analysis of regional wall motion
  abnormalities

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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
• gt 6 months underestimation volume of necrosis

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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

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Mitral regurgitation

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

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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

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Prognosis
EF and Mortality
20
lt 30
6-monthmortality
Viability Domain
10
30 - 39
Ischemia Domain
40 - 49
50 - 59
gt 80
0
20
30
40
50
60
70
Echocardiographic Ejection Fraction ()
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Wall Motion Score
LV wall motion and scoring . Scoring
LV wall motion score index
total score Total scored segments
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Scoring system for grading wall motion (table
10-1)
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RV-infarction (table 10-3)
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Complications detected by echo (table 10-4)
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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

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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

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Pericarditis and pericardial effusion (18-44)

• 3-10 days after Q-wave infarction
• gt 10 days Dressler
• larger infarctions have more pericardial effusion

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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

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Mitral regurgitation - echo

• 2D abnormalities in mitral valve apparatus
• Color flow grading
• Doppler flow velocity

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Mitral valve incompetence
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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

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Apical VSR
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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

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True and false aneurysm(fig 10-9)
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LV-thrombus

• most common left ventricular apex
• large apical aneurysm, oral anticoagulation is
  recommended

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Mural Thrombus
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Resuscitation
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Resuscitation
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Resuscitation
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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

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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

OBrien Am Heart J 1984
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Sensitiviteit om klepvegetaties aan te tonen

• Transoesafageale echocardiografie 92

Chest 1994 105 377-382
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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

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Complicaties zichtbaar met echo

• Absces in de annulus
• Fistels
• Ernstige insufficientie
• Paravalvulaire lekkage
• Kunstklepdehiscentie
• Kunstklep obstructie

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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 zn minst een keer
  tijdens de ziekte een TEE onderzoek te ondergaan
• Ervaren onderzoekers zijn essentieel

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Endocarditis
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Mitral Valve Vegetation
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The Small Echo Machine
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Stetoscope versus Echo

• 36 patients
• cardiac exam followed by exam with small echo
  machine
• 79 cardiovascular findings
• 34 major cardiovascular abnormalities

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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

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Auscultation versus Echo
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Echo is a HorseMostly a workhorseSometimes a
Lipizaner