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