Echocardiography after stroke - where to look
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1 Echocardiography after stroke - where to look Vuyisile T. Nkomo, MD,MPH, FACC, FASE Joint Cardiac Imaging Society of South Africa/Mayo Clinic Echocardiography Workshop MFMER slide-1
2 Disclosures No relevant financial disclosures 2016 MFMER slide-2
3 Cardiac Sources of Embolism: TEE superior vs TTE Cardiac tumor, vegetation or thrombus Left atrial appendage thrombus Aortic plaque Patent foramen ovale (PFO) Atrial septal aneurysm 2016 MFMER slide-3
4 27-year-old male Expressive aphasia and loss of vision 2016 MFMER slide-4
5 Clinical context Previous myocardial infarction 4 years prior DSE to LAD Stopped Clopidogrel because of rash 3 months prior to stroke Recurrent myocardial infarction Rx with PCI Suspected LV thrombus Warfarin > Hematuria Stopped Warfarin 2016 MFMER slide-5
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9 Mass most likely 1. Myxoma 2. Angiosarcoma 3. Melanoma 4. Thrombus 5. Infective vegetation 2016 MFMER slide-9
10 LV aneurysmectomy and thrombectomy 2016 MFMER slide-10
11 41-year-old with hemorrhagic stroke PMH cerebral vasculitis for 2 years Myxoma 2016 MFMER slide-11
12 41-year-old with hemorrhagic stroke PMH cerebral vasculitis for 2 years 2016 MFMER slide-12
13 A B C LA LA RA AO E D E 2016 MFMER slide-13
14 Myxoma 2016 MFMER slide-14
15 46-year-old male with posterior circulation TIA PMH chronic atrial fibrillation No change in mass after 1 month of therapeutic anticoagulation 2016 MFMER slide-15
16 Angiosarcoma 2016 MFMER slide-16
17 Left Ventricle Sarcoma 2016 MFMER slide-17
18 Other cardiac tumors Metastatic colon cancer 2016 MFMER slide-18
19 Other cardiac tumors Papillary Fibroelastoma 2016 MFMER slide-19
20 Lambl s excrescence, fenestration Vegetation: Infective, Noninfective Sclerosis / calcium artifact Thrombus (prosthesis) Mobile Endocardial Echodensity Ruptured/ retracted chordae Papillary fibroelastoma, myxoma Valvular Strands Myxomatous tissue 2016 MFMER slide-20
21 Accuracy of Echo: Diagnosis of Valvular Vegetations TTE TEE Resolution 3-4 mm 1-2 mm Sensitivity 62-82% % Specificity % % Pederson WR et al. Chest 100:351; 1991, Jacob, S et al. Curr Opin Cardiol 17:478; 2002, Casella, F et al. Echocardiography 26: 900, 2009, Kini, V et al. J Am Soc Echocardiogr 23: 396, MFMER slide-21
22 Detection of Prosthetic Valve Vegetations TEE is superior TTE TEE Sensitivity 17-44% % Note: Approximately 30% of cases of prosthetic valve endocarditis have no vegetations attached to the prosthesis, only peri-annular infection Jacob, S et al. Curr Opin Cardiol 17: 478, 2002 Graupner C, et al. JACC 2002; 39: 1204 Kini V, et al. J Am Soc Echocardiogr 23: 396, MFMER slide-22
23 Lambl s excrescence 2016 MFMER slide-23
24 Calcified nodule of Arantius 2016 MFMER slide-24
25 33-year-old female with transient hemianopia PMH mitral valve tissue prosthesis Bioprosthesis thrombosis 2016 MFMER slide-25
26 Post-warfarin 2016 MFMER slide-26
27 Duke Major Criteria Diagnosis of Infective Endocarditis 1.Positive Blood Cultures ( 2) Typical organisms (Staph aureus, Strep viridans or bovis, HACEK, Enterococci) Persistent bacteremia ( 3) (Staph epidermidis, Gram negative bacilli) Single +blood culture for Coxiella burnetii or anti-phase 1 IgG antibody titer >1:800 Durack et al. Am J med 1984; Li et al. Clin Infect Dis MFMER slide-27
28 Duke Major Criteria Diagnosis of Infective Endocarditis 2. Evidence of Endocardial Involvement Positive Echocardiogram Vegetation Peri-valvular abscess Prosthetic valve dehiscence New valvular regurgitation FDG-PET/CT or SPECT/CT* *(ESC 2015) Durack et al. Am J med 1984; Li et al. Clin Infect Dis MFMER slide-28
29 Duke Minor Criteria: Diagnosis of IE 1. Predisposing condition Prosthetic valves IV drug use or valvular disease 2. Fever: Temperature >38ºC (100.4ºF) 3. Vascular phenomena Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhages, conjunctival hemorrhages, Janeway lesions 4. Immunologic phenomena Glomerulonephritis, Osler's nodes, Roth s spots and rheumatoid factor 5. Other microbiologic evidence: +blood culture not meeting major criteria Durack et al Am J med, 1984; Li et Clin Infect Dis MFMER slide-29
30 Typical Echo Features of Vegetations Attachment on upstream side of the valve leaflet. Vegetations prolapse into the upstream chamber. Veg motion almost independent of valve motion MFMER slide-30
31 NonBacterial Thrombotic Endocarditis Libman-Sacks Endocarditis 2016 MFMER slide-31
32 Atrial Fibrillation 2016 MFMER slide-32
33 Atrial Fibrillation: Stroke 5-fold increased risk of stroke 30 AF prevalence Strokes attributable to AF 15% of all strokes attributable to AF AF related strokes have worse outcomes 90% of all thrombi non-rheumatic AF from LAA % Age range (yr) Wolf et al. Stroke 1991;22: , Marini et al. Stroke 2001; 32: Blackshear: Ann Thoracic Surg 61, MFMER slide-33
34 LA/LAA Thrombus Dense SEC LAAEV 20 cm/s Left atrial abnormality 7.8%/yr Both 20.5%/yr Complex aortic plaque 12.0%/yr Neither 1.3%/yr SPAF III Ann Int Med, 1998 CP
35 eft Atrial Appendage: Pectinate Muscles Stöllberger C et al. Z Kardiol 2003;92:
36 2016 MFMER slide-36
37 Peak Emptying Velocity 52 cm/sec 2016 MFMER slide-37
38 Contrast 2016 MFMER slide-38
39 Left atrial appendage thrombus 2016 MFMER slide-39
40 Spontaneous echo contrast (SEC) 2016 MFMER slide-40
41 Contrast helpful to determine if thrombus present 2016 MFMER slide-41
42 2016 MFMER slide-42
43 Atherosclerotic Disease of the Aorta Risk of Stroke Ascending aorta and prox arch Plaque thickness (mm) *Adjusted Odds ratio (95% CI) < 1 Reference ( ) ( ) ( ) ( ) *After adjustment for age, sex, HTN, smoking status, cholesterol level, DM, previous MI, and AF Amarenco P et al. N Engl J Med ;331:
44 Atrial septum aneurysm Patent foramen ovale 2016 MFMER slide-44
45 2016 MFMER slide-45
46 2016 MFMER slide-46
47 Cardiac Sources of Embolism: TEE superior vs TTE Cardiac tumor, vegetation or thrombus Left atrial appendage thrombus Aortic plaque Patent foramen ovale (PFO) Atrial septal aneurysm 2016 MFMER slide-47
48 Thank you 2016 MFMER slide-48
49 Acknowledgments N. Ammash, MD Y. Maalouf, MD R. Melduni, MD, MPH S. Pislaru, MD, PhD 2016 MFMER slide-49
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