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

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