Like your first colour TVECHO BEYOND POCUS & OTHER APPETIZERS

Dr. P. JANINRoyal North Shore Hospital - Sydney

Some Story

Obese male Poorly documented past medical history No usual medications Elective cystoscopy /GA

Becomes hypoxic 15 min post induction Copious amount of frothy proteaceous liquid in

ETT Rapidly impossible to ventilate Cardiac arrest. Immediate CPR. ROSC. Remains hypoxic on high PEEP / FiO2. High

dose inotropic support Presumed aspiration?

Some Story

Some Question

V-V ECMO Remains on high dose inotropic support Metabolic acidosis. pH 7.18. Relative bradycardia.

The Question

RV dysfunction ?

• Previous RHF• Acidosis / CPR• High PEEP

The Tool

The Problem

2D Areas <> Volumes Volume change <> Contractility Ideal volumes & Starling curve

Geometry

Heart chambers can have a complex geometry.

EF & Simpson’s method make many assumptions.

Right Ventricule

Geometry

EF is not a measure of contractility.

EF is a measure of the global systolic effect, and is highly dependent on load.

Caveats

Echo can only measure deformation.

80% of the systolic work is done during the Isovolumic Contraction Time.

Strain Imaging

Not that new Measures deformation of

ventricular walls: shortening and elongation.

Part of tissue motion tracking. Much more simple than it sounds.

Speckle Tracking

Grayscale pictures consist of a speckled pattern, produced by the interference pattern of reflected ultrasounds.

Each portion of the myocardium has a unique speckle pattern, that can be tracked.

Strain Imaging

Displacement Curve Strain (Deformation) Curve

Strain Imaging

Strain Rate

Rate of relative deformation

Closely related to tissue velocities

Strain Rate

Deformation Imaging

Imaging of wall motion instead of chambers change.

Evolution on the concept of cardiac performance.

Benefits

Strain rate and Tissue velocity are closer to contractility than global measures such as EF, strain, global displacement.

Comparative study of segments. Prognostic value and early detection of cardiomyopathy (heart

failure, Anthracyclines toxicity, MV repair). Synchrony. Some reproducibility for follow-up.

Deformation Imaging

Limited feasibility and accuracy. Relies on high quality pictures (speckle tracking). Challenging interpretation.

3D live: Thin slice mode

3D live: Zoom mode

3D Imaging: Biplane view

3D FV:Tomographic slice

3D FV:Volume rendering

3D FV:Surface rendering

3D FV:Surface rendering

3D FV:Colour Doppler

3D FV:Colour Doppler

3D Echo: Benefits

Multi-plan imaging. Fast acquisition. Volume assessment of complex

chambers. Improved view on complex problems

(valvular lesions, VSD, …).

Contrast Imaging

Contrast Imaging

So What ?

2D echo is not always the straight forward answer to cardiac assessment

What we see is not always unravelling what we need to measure

So What ?

Better technology for more accuracy:

When machines start to properly eyeball the heart, and explore all aspects of its complexity.

Thank you

Thank you to Dr. T. Kapalli (St George Hospital)

Thank you to Dr. Stoylen for his excellent online resource