role of imaging in acute cardiovascular care · 2019. 6. 26. · tatiana guimarães, santa maria...

Role of imaging in acute cardiovascular care

TatianaGuimarãesDepartmentofCardiology,SantaMariaUniversityHospital,CHLN

CenterofCardiologyoftheUniversityofLisbon(CCUL),FacultyofMedicineLisbonAcademicMedicalCenter

Lisboa,Portugal

February 24th 2019

Tatiana Guimarães, Santa Maria University Hospital, Lisboa, Portugal

Imaging techniques in acute cardiovascular care

§ Chest X-ray

§ Ultrasound- Echocardiography (TT/TE)- Thoracic- Vascular

§ Computed tomography angiography- Coronary- Pulmonary- Aorta

§ Cardiac magnetic resonance

ü Diagnosisü Treatment decisions

ü Follow upü Prognosticstratification


§ Chest X-ray

- Diagnosis and follow up- Device placements


✘ Radiation exposure ✘ Low specificity

✘ Limited correlation with hemodynamic parameters


§ Chest X-ray- Diagnosis and follow up

Right-sided pleural effusion Pericardial effusion


Water retention-related problems


(A)Subcutaneous emphysema.(B)Large b ilateraltension pneumothorax.(C) Pneumomediastinum.(D)Pneumoper icard ium.


Air-related problems



Pneumonia (opacity in right lower lobe)


Lung-related problems


Massive PE (enlargement of the r ight pulmonaryartery-Palla’s sign), oligaemia of pulmonary vessels(Westmark`s sign)

Pulmonary oedema (bat wing opac ities, Kerley Alines running to the periphery)


ARDS (bilateral airspace opacities and increasedinterstitial markings in a patient with acuterespiratory failure)


Lung-related problems


Aspiration pneumon ia (r ight lower lobeconsolidation, right-sided pulmonary oedema)



§ Chest X-ray- Device placements

• Endotracheal tubes• Central venous catheters• IABPs• Pacemakers leads • Chest Tubes and drains

Correctly placed ETT




• Endotracheal tubes• Central venous catheters• IABP • Pacemakers leads • Chest Tubes and drains

Coiled CVC





IABP





Pacemaker leads





Partial resolution of r ight-sided pneumothorax aft er chest tubeplacement



§ UltrasoundEchocardiography vs FoCUS

Cholley et al. 2006; Price et al., 2008



§ UltrasoundFoCUS

• Standardized andrestricted, scanningprotocol

• Extension of the clinicalexamination

• To detect a limitednumber of critical cardiacconditions

• Immediate decisionsNescovik et al., EHJ. 2018



§ UltrasoundFoCUS



§ UltrasoundFoCUS

✘Time-constrains

✘Restricted image acquisition protocol

✘ Risk of missing important abnormalities

✘Operator experience

✘ Technic equipment technically inferior

✘ Stressful situationsNescovik et al., EHJ. 2018



§ UltrasoundFoCUS

• Lung ultrasound- pulmonar edema- pleural effusion- pneumothorax

Interstitial pulmonary edema (B lines)



§ UltrasoundFoCUS


Pleural effusion



§ UltrasoundFoCUS


Normal lung will show a “seashore s ign” with transit ion of lines d ifferentiat ing movement at thepleural lines, whereas pneumothorax prevents detection of mot ion creating a single “bar code”pattern



§ UltrasoundFoCUS

• Lung ultrasound

Pivetta et al., EHJ. 2019



§ UltrasoundFoCUS

• Lung ultrasound



§ UltrasoundEchocardiography vs FoCUS

Cholley et al. 2006; Price et al., 2008



§ Echocardiography in specific scenarios

Acute coronary syndromes – diagnosis

Thygesen et al., EHJ. 2018




Acute coronary syndromes – complications and prognosis

Ibanez et al., EHJ. 2018

Roffi et al., EHJ. 2016

EMERGENTEChoque cardiogénicoInstabilidade hemodinâmicaSuspeita de complicações mecânicas

ROTINAAvaliação da função ventricularPrognósticoTerapêutica




Acute coronary syndromes – complications and prognosis

• Left ventricular dysfunction• Right ventricule infarctation• Trombus• Aneurysms• Mitral regurgitation

- tethering- chordal rupture- papilary muscle rupture

• Ventricular septum defect• Ventricular free wall rupture




Acute coronary syndromes – complications and prognosis• Left ventricular dysfunction




Acute coronary syndromes – complications and prognosis• RV infarctation




Acute coronary syndromes – complications and prognosis• Trombus




Acute coronary syndromes – complications and prognosis• Mitral regurgitation (papillary muscle rupture)




Acute coronary syndromes – complications and prognosis• Mitral regurgitation (leaflets thetering)




Acute coronary syndromes – complications and prognosis• Ventricular septum defect




Acute coronary syndromes – complications and prognosis• Pseudoaneurysm




Takotsubo syndrome




Heart Failure

• Systolic left ventricular function

Ejection fraction: Simpson biplane3D Contrast

Myocardial deformation




GLS has greater prognostic value

than LVEF




Heart Failure

• Diastolic left ventricular function• Etiology• Mitral regurgitation• RV dysfunction• Prognosis• Treatment




Heart Failure

Ponikowski et al., EHJ. 2018




Heart Failure

• Non-invasive hemodynamic assessment

Cardiac output

Volume status- Central venous pressure (IVC and respiratory variation)- LV filling pressures (E/e`)

Pulmonary pressures- PSAP




Circulatory support therapies

• Candidate patients• Type of support• Optimization• Widrawal or weaning




Circulatory support therapies

• ECMO V-A




Endocarditis

Habib et al., EHJ. 2015




Valvular disease

• Regurgitation• - Acute vs chronic• Stenosis• Hemodynamic consequences




Prosthetic valve dysfunction

• Ring dehiscence• Thrombosis




Prosthetic valve dysfunction• Ring dehiscence




Prosthetic valve dysfunction• Thrombosis



§ Echocardiography in specif scenarios

Pericardial disease

• Pericardial effusion- Tamponade

• Constritive pericarditis




Pericardial disease• Pericardial effusion

- Tamponade




Pericardial disease• Constritive pericarditis




Pulmonary embolism

Konstantinides et al., EHJ. 2015




Pulmonary embolism




Aortic emergencies• Aortic dissection• Intramural haematoma• Penetrating ulcer• Symptomatic aneyrism

Erbel et al., EHJ. 2014




Aortic emergencies• Aortic dissection




Traumatic cardiac injury



§ Computed tomography angiography

• Coronary• Pulmonary• Aorta




• Coronary

Roffi et al., EHJ. 2016




• Pulmonary

Konstantinides et al., EHJ. 2015

(A) Mass ive emboli in the left and right pulmonar arter ies (B) Severe d ilationof the right ventricule




• Aorta

Type A aortic dissection

Erbel et al., EHJ. 2014




• “Triple rule out”

ü Exclude potentialy life-threating causes of acute chest painü Faster algorithmü Low admission rates

✘ Radiation exposure ✘ Contrast

✘More RCT are need ...

Chae MK et al., J. Cardiovasc Comput Tomograf., 2016Turaco M et al., ESC Textbook, 2015




ü Etiology- Acute coronary syndrome/MINOCA- Miocarditis- Pericarditis- Takotsubo syndrome- Aortic disease- ...

ü Left/right ventricular functionü Ischaemia/viabilityü Prognosis

✘ Hemodynamic instability ✘ Metallic implants, devices, ...

✘ Gadolinium contrast




ü Etiology




ü Left/right ventricular function




ü Viability

Kim et al. N Eng J Med 2000




ü Viability

Anavekar et al. Revascularization in Severe LV Dysfunction. JACC Vol. 67, No. 24, 2016



§ TAKE HOME MESSAGES

o Imaging techniques are indispensable for clinical decision-making

o Chest X-ray is an easy-to-use and may reveal unsuspected clinicalconditions

o FoCUS and lung ultrassound are extension of the clinical examination

o “Triple rule-out” approach may improve the triage of patients presentingwith acute chest pain

o Current applications of cardiac magnetic resonance offer a widespectrum of indications in the setting of acute cardiac care

role of imaging in acute cardiovascular care · 2019. 6. 26. · tatiana guimarães, santa maria...

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