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

1. Echocardiography in the clinical situation: what can we do with it? LHB Baur, MD,PhD

2. The First Aid Department

3. Reasons for chest pain • Acute myocardial infarction • Unstable angina • Pericarditis • Dissection of the aorta • Syndrome X • Cholecystitis • Oesophagitis

4. More reasons: • Aortic stenosis • Hypertrophic cardiomyopathy • Mitral valve prolapse

5. Pathophysiology after coronary occlusion • 1. Diastolic abnormalities (< seconds) • 2. Systolic contractile dysfunction • 3. EKG abnormalities

6. Diagnosis of myocardial infarction • Clinical history + • Electrocardiogram + • Enzymes

7. Regional Contractile Abnormalities • Reduced inward wall motion • Decreased wall thickening • Dyskinesis

8. Infarct location and coronary vessel involved Agreement = 76%

9. Infarct location and coronary vessel involved Agreement = 81%

10. The ECG • The diagnostic markers of injury are ABSENT in 50 % of patients with acute myocardial infarction

11. 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

12. 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

13. Parasternal Long Axis

14. Parasternal short axis

15. Apical 4 Chamber

16. Apical 2 Chamber

17. 16-segment model for wall motion analysis

18. Arterial distribution (fig 10-2)

19. Inferior infarction

20. Anteroseptal infarction

21. 2 Chamber View

22. Long Axis

23. Short axis

25. Aortic valve stenosis

26. Hypertrofic cardiomyopathy

27. Pericarditis

28. Mitral valve prolapse

29. Aortic Dissection

30. Relation between extent of infarction and thickening 40 30 20 10 Systolic thickening (%) 0 -10 -20 0 1-20 21-40 41-60 61-80 81-100 Infarct thickness (%) Lieberman; Circ: 1981: 63: 739

31. 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

32. 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%

33. 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%

34. Role in patient triage 80 patients admitted with chest pain 15 technically difficult 36 abnormal RWM on echo 29 normal RWM on echo 2 subendocardial infarction 27 no MI 31 clinical MI 5 no clinical MI 29 no complications 10 cardiac complications 3/3 had CAD on angiography Horowitz Circ 1982; 65: 323-329

35. Echo in patient triage 43 patients admitted with chest pain 25 abnormal RWM on echo 18 normal RWM on echo 4 subendocardial infarction 14 no MI 22 (88%) clinical MI 3 (12%) no clinical MI CH Peels: Am J. Cardiol 1990: 65: 687-691

36. Echo in Myocardial Infarction

37. 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

38. Chest Pain evaluation unit Symptoms of acute ischemia History of CAD Hemodynamic instability ST  or ST  > 1 mm Unstable angina 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% Direct Hospital Admission Gibler Ann Emerg. Med 1995; 25: 1-8

39. Treat for AMI or unstable angina Diagnostic ECG Chest Pain Nondiagnostic ECG 2D Echo Normal Wall motion during chest pain Normal Wall motion in abscence of chest pain Regional Wall motion abnormality Acute or old Myocardial Infarction Outpatient evaluation Stress echo

40. Echocardiography in the CCU Acute myocardial infarction Detection of complications Prognostic implications

41. Advantages/Limitations • Advantage: • portability • noninvasive • anatomic and hemodaynamic information • Limitations: • limited transthoracic windows • only qualitative analysis of regional wall motion abnormalities

42. 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

43. 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

44. Mitral regurgitation Incomplete coaptation due to papillary muscle ischemia • especially inferolateral or posteromedial (only RCA) papillary muscle • severe global LV-dysfunction (large anterior infarction)

45. 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

46. Prognosis EF and Mortality 20 < 30% % 6-monthmortality Viability Domain 10 30 - 39% Ischemia Domain 40 - 49% 50 - 59% > 80% 0 20 30 40 50 60 70 Echocardiographic Ejection Fraction (%)

47. Wall Motion Score LV wall motion and scoring . Scoring; = LV wall motion score index total score Total scored segments

48. Scoring system for grading wall motion (table 10-1)

49. RV-infarction (table 10-3)

50. Complications detected by echo (table 10-4)