Echo Emergencies Michael H. Picard, MD Massachusetts General Hospital Harvard Medical School No disclosures Outline Common emergency / on call scenarios Tamponade Pulmonary embolism/rv strain Cardiogenic shock / MI complications / volume status Chest pain and LBBB Aortic dissection Transplant donor evals and OHT rejection Volume status (IVC imaging) Prosthetic valve thrombosis/obstruction Mechanical Circulatory Support malfunction Post-cardiac surgery hypotension 2 1
Cardiac Tamponade Echocardiographic findings in Cardiac Tamponade Pericardial effusion RV free wall inversion early diastole, respiratory variation RA inversion late diastole, early systole: >33% of cycle IVC plethora exaggerated Doppler respiratory variation in transvalvular flow IVC, TV, PV: insp, exp MV, AV: insp, exp 2
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Gillam et al Circ 1983;68:294-301 4
Hypotension immediate post-cardiac surgery TTE images tough Hematoma rather than free flowing fluid May be difficult to see even when images are good Often localized behind RA Doppler flow variations may be the best clue of elevated intra-pericardial pressure Clinical judgement required TEE vs. go back to OR without confirmation 10 5
Pulmonary embolism TTE should not be performed to diagnose PE (i.e., to look for the thrombus) It is used to assess presence of RV strain which may impact treatment decisions 11 RV strain in the setting of pulmonary embolism aka McConnell s Sign Am J Card 1996;78:469-73 6
Chest pain and LBBB is it ACS? 13 Type I aortic dissection 7
Who says you can t diagnose aortic dissection with TTE? 15 Echocardiographic findings Intimal flap High frequency, low amplitude motion flow respects the boundary Artifacts Motion - Low frequency (or same frequency as adjacent structure) and high amplitude Color flow goes through +/- aortic dilation Aortic insufficiency Wall motion abnormality if flap obstructs coronary ostia 8
Echo for Aortic Dissection TEE Sensitivity 98-100% and specificity 77-100% in different series False negative TEE is rare: few dissections are limited to the blind spot at the inferior portion of the arch False positive TEE: Artifacts are very common (23-55%), especially in the ascending aorta. Artifacts Side-by-side: lateral resolution, side lobe, lens effect Behind, parallel motion: Reverberation Behind, opposite motion: Mirror image 9
Linear TEE artifacts artifacts in the aorta seen in the presence of dilated aortas Artifact distance = 2 times that of interface Transverse TEE image of dilated ascending aorta compressing LA. Note the artifact crosses borders Appelbe et al, JACC 1993;21:754-60 Clues to artifacts Cross borders motion identical to another real structure amplitude and frequency at a multiple of the real structure indistinct edges not reproduced in an orthogonal or other view color flow passes through it clues - foreign materials present catheters, prosthetic valves, grafts these are not always in the plane of view 10
Clues to real structures respects borders distinct edges (unless thrombus) motion intimal flaps - amplitude and frequency of motion different than cardiac cycle, respiration seen in multiple views color flow respects true borders intimal flaps keep company other pathologic processes LVAD or other Mechanical Circulatory Support potential complications Aortic dissection AI of native valve ; Aortic valve thrombosis Conduit obstruction / kinking Worsening of RV failure Inlet cannula thrombosis Overpumping Pump failure Bleeding / hematoma infection 22 11
LV underfilled (overpumping, RPMs too high) LVAD complications 12
Device malfunction due to thrombus response to changing pump speed Image at lowest pump speed, increase to maximum pump speed (2 min/intermediate stages) Normal response LVEDd decrease Decrease in AV opening duration RV stroke volume increases Increased MV deceleration time If obstruction (ie., thrombus) No change in LVEDd, AV opening, RV SV, Decreased LV deceleration time MV E wave decrease and deceleration time increase with increased LVAD pump speeds = reduction in LV diastolic pressures Estep et al JACC CV Img 2010;3:1049-64 13
61 yo with VV ECMO and hypotension RA-PA ECMO for severe COPD, awaiting lung transplant TTE for? Pericardial effusion/tamponade 14
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Cardiac Transplant on call echoes Donor assessment Assess LV function, valve disease Transplant rejection Reduced LV function (compare to prior) Myocardial edema (increased wall thickening) Not seen with certain immunosuppressives Non-compliant LV (diastolic dysfunction) Mainly with cyclosporine Nonspecific may occur just due to increased LA pressure 32 16
Cardiogenic Shock (CS) after MI: etiologies and outcome from a large registry 1190 CS pts eligible but not randomized to SHOCK Trial (mechanical complications excluded) etiologies: LV failure 78.5% severe MR 6.9% ventricular septal rupture 3.9% isolated RV shock 2.8% tamponade 1.4% other (severe valve ds, hemorrhage, sepsis) 6.7% ventricular septal rupture - highest mortality (87.3%) Hochman et al JACC 2000;36:1063-70 Cardiogenic shock post-mi ventricular septal rupture 34 17
Cardiogenic shock post-mi papillary muscle rupture 35 Cardiogenic shock post-mi pseudo aneurysm 18
Cardiogenic shock post-mi free wall rupture Elderly diabetic woman with several days of malaise and chest pain. Low BP in ED. TEE for aortic dissection. No dissection but LV EF reduced and pericardial effusion Bimbaum Y, et al. N Engl J Med. 2002; Edwards BS, et al. Am J Cardiol. 1984; Mann JM, Roberts WC. Am J Cardiol. 1988 Cardiogenic shock just a bad LV 38 19
Hypotension assessing preload by IVC size 39 IVC size and respiratory dynamics 40 Normal IVC size 50% decrease in diameter = normal RA pressure Dilated IVC Normal inspiratory collapse (> 50%) suggestive of mildly elevated RA pressure (6-10 mm HG) Inspiratory collapse < 50 % RA pressure 10-15 mm HG No collapse suggests markedly elevated RA pressure of > 15 mm Hg Small IVC (< 1.2 cm) with spontaneous collapse often is seen in the presence of intravascular volume depletion 20
Prosthetic valve thrombosis Occurs in both mechanical and biological prostheses Stenosis with or without regurgitation Gradual or sudden onset of symptoms 2X higher in MV than AV Keys on echo Movement of occlude Doppler gradients Pattern of flow / regurgitation 41 GMK 53 yo F remote hx of Hodgkin s ds (s/p XRT to chest) AS/AI, MR, TR Progressive heart failure Day 14 s/p AVR/MVR Difficult to diurese LFTs now markedly elevated New dyspnea Supratherapeutic INR On call echo to assess for TR, paravalvular leak, pericardial effusion/tamponade 42 21
New SOB 2 weeks after AVR/MVR 43 44 22
TTE 45 Small LV IVS flattening in diastole and systole RV volume and pressure overload Aortic bileaflet mechanical prosthetic valve = ok Peak 18 mm Hg, mean 10 mm Hg, trace valvular AI Mitral bileaflet mechanical prosthesis Restricted motion of 1 of the disks Peak 31 mm Hg, mean 17 mm Hg (2 weeks earlier mean = 6 mm Hg) Severe TR Trivial pericardial effusion Peak gradient 25 mm Hg; mean 15 mm Hg mean formerly was 6 mm Hg (2 weeks prior) 46 23
Before and after 47 24