Role of echocardiography in the assessment of ischemic heart disease 분당서울대학교병원윤연이

Role of echocardiography in the assessment of ischemic heart disease 분당서울대학교병원윤연이

Outline Evaluation of Chest pain Evaluation of MI complications Prediction of Outcomes

Evaluation of Chest pain Evaluation of MI complications Prediction of Outcomes

Ischemic cascade

Regional Wall Motion Abnormality (RWMA) Wall motion score index (WMSI)

Regional Wall Motion Abnormality (RWMA) Typical coronary artery distribution of blood flow Otto et al. Echocardiography review guide

RWMA in CAD Mid anteroseptal wall and whole apex akinesia LAD territory ischemic insult

RWMA in CAD Mid LAD tight stenosis

Limitation of Echocardiography Echocardiography does not allow direct evaluation of coronary artery stenosis. LV global and regional function can be normal at rest even when significant coronary artery disease is present.

Stress echocardiography Evaluation of inducible myocardial ischemia Exercise stress echocardiography Treadmill exercise echocardiography Supine bicycle exercise echocardiography Pharmacological stress echocardiography Dobutamine stress echocardiography Ergonovine stress echocardiography

Exercise echocardiography Baseline Treadmill Supine bicycle Excercise Immediate Post-excercise Recovery

Treadmill echocardiography Baseline Treadmill Excercise Imaging during exercise is not feasible Highest workload Immediate Post-exercise Recovery Echo imaging

Treadmill echocardiography M/65, typical effort chest pain Baseline ECG Peak exercise ECG

Exercise echocardiography Baseline Supine bicycle Excercise Immediate Post-excercise Recovery

Supine bicycle echocardiography Baseline Supine bicycle Echo imaging It is possible to obtain images during the various levels of exercise Excercise Immediate Post-excercise Recovery Lower workload

Supine bicycle echocardiography Bicycle stress echo: 1. diastolic stress 2. ischemic stress 3. pulm. HTN And, VmaxO2, VE/VCO2 AT, wheezing, SO2 Baseline 50W Peak, 125W

Dobutamine stress echocardiography In patients who cannot exercise, pharmacological stress are alternatives. Dobutamine is preferred when the test is based on assessment of regional wall motion. SNUBH protocol 40 Atropine 2.5mg x 4 30 20 10 Dobutamine (μg/kg/min) Β-blocker 0 3 6 11 16 20

Dobutamine stress echocardiography M/78, chest pain, history of stroke

Dobutamine stress echocardiography Patterns of wall motion with dobutamine stress echo Normal Ischemia Stunned or Hibernating Infarction Baseline Normal Normal Hypokinetic Akinetic Hypokinetic Akinetic Low dose Normal Normal Improved Hypokinetic Akinetic High dose Hyperkinetic Hypokinetic Akinetic Hypokinetic Akinetic Hypokinetic Akinetic

Ergonovine stress echocardiography M/54, morning chest pain

Evaluation of Chest pain Evaluation of MI complications Prediction of Outcomes

MI complications LV dysfunction Cardiogenic shock RV infarction Papillary muscle rupture Acute mitral regurgitation Ventricular septal defect, cardiac rupture LV aneurysm LV thrombus Pericardial effusion, tamponade

Major advantages of echocardiography Availability Portability Short examination time Low cost Assessment of hemodynamics

LV Aneurysm Known ICMP, s/p CABG

LV Aneurysm h/o PCI to LAD Routine echocardiography Contrast echocardiography

Intracardiac thrombus STEMI, s/p PCI to LAD

LV aneurysm M/63, dyspnea: PL branch total occlusion

True- vs. Pseudo-aneurysm

F/67, dyspnea Pseudoaneurysm Routine echocardiography Contrast echocardiography

F/67, dyspnea Pseudoaneurysm

Ventricular free wall rupture F/85, palpitation, chest pain, dyspnea OM total occlusion

Ventricular free wall rupture F/85, palpitation, chest pain, dyspnea

VSD STEMI, s/p PCI to LAD

M/67, Known 3VD Ischemic MR

Ischemic MR F/56, chest pain, dyspnea

Evaluation of Chest pain Evaluation of MI complications Prediction of Outcomes

LV ejection fraction Volumetric measurement M-mode echocardiography

LV ejection fraction 767 patients with AMI Median follow-up : 19 months Primary EP : all-cause mortality LVEF provide powerful prognostic information after AMI AHJ 2006;151:419-25

Wall motion score index Predictive power of WMSI is greater. AHJ 2006;151:419-25

LV diastolic function Circulation 2006;114:438-44

Mitral deceleration time 646 patients with AMI DT 130 msec : restrictive group (n =147) DT >130msec : nonrestrictive group (n = 424) JACC 2004;43:1346-53

LA volume 395 patients with AMI LAVI >32 ml/m 2 (n =63) vs. LAVI 32 ml/m 2 (n = 332) Independent 5-year mortality risk predictors JACC 2004;44:327-34

Myocardial deformation imaging Myocardial strain is a measure of the deformation in shape and dimension of the heart muscle during the cardiac cycle. Myocardial strain imaging provide more direct and sensitive evaluation of myocardial function.

Speckle tracking echocardiography SNUBH

Prognostic value of strain 659 patients after AMI Primary endpoint : all-cause mortality Secondary endpoint : revascularization, re-infarction, HF hospitalization Strain was independent related to all endpoint and was superior to LVEF, and WMSI EHJ 2010;31:1640-7

Prognostic value of strain 659 patients after AMI Primary endpoint : all-cause mortality Secondary endpoint : revascularization, re-infarction, HF hospitalization EHJ 2010;31:1640-7

Prognostic value of strain 849 patients after AMI with LVEF >40% Primary endpoint : all-cause mortality, HF hospitalization Secondary endpoint : cardiac death, HF hospitalization JACC 2013;61:2365-73

Thank you! Yeonyee E. Yoon (yeonyeeyoon@gmail.com)