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) EKG LAD RDP RCX Anterior 22 2 2 Inferior 3 33 8 Postero- 1 lateral 4 7 Agreement = 76% Infarct location and coronary vessel involved Infarct Location (Angio) ECHO LAD RDP RCX Anterior 21 4 1 Inferior 2 30 5 Postero- 0 lateral 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 Systolic thickening (%) 40 30 20 10 0 -10 -20 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 triage 80 patients admitted with chest pain 15 technically difficult 36 abnormal RWM on echo 31 clinical MI 10 cardiac complications 29 normal RWM on echo 5 no clinical MI 3/3 had CAD on angiography 2 subendocardial infarction 27 no MI 29 no complications Horowitz Circ 1982; 65: 323-329 Echo in patient triage 43 patients admitted with chest pain 25 abnormal RWM on echo 22 (88%) clinical MI 18 normal RWM on echo 3 (12%) no clinical MI 4 subendocardial infarction 14 no 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 unit Symptoms of acute ischemia History of CAD Hemodynamic instability ST or ST > 1 mm Unstable angina Direct Hospital Admission 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% Gibler Ann Emerg. Med 1995; 25: 1-8 Diagnostic ECG Treat for AMI or unstable angina Chest Pain Nondiagnostic ECG 2D Echo Normal Wall motion during chest pain Normal Wall motion in abscence of chest pain Outpatient evaluation Stress echo Regional Wall motion abnormality Acute or old Myocardial Infarction Echocardiography in the CCU Acute myocardial infarction Detection 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 Prognosis 20 EF and Mortality < 30% % 6-month mortality Viability Domain 10 30 - 39% Ischemia Domain 40 - 49% 50 - 59% > 80% 0 20 30 40 50 Echocardiographic Ejection Fraction (%) 60 70 Wall Motion Score LV wall motion and scoring . Scoring; = LV wall motion score index total score Total scored segments 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 auscultation echocardiogram normal abnormal normal 42 0 abnormal 21 9 Echo is a Horse: Mostly a workhorse Sometimes a Lipizaner