You Won t Believe What I Saw on that ECHO! Dimensions 2013 October 18 th Michael Pfeiffer, MD Disclosures No Financial Disclosures Goals Review unusual and unique echocardiographic images. Briefly present associated clinical context. Review some clinical and imaging pearls associated with the underlying diagnoses. 1
Patient 1 71 year old female with prolonged history of dyspnea and hypoxia requiring oxygen. Has had a work up including PFTs, Chest CT, and trans thoracic ECHO. PFTs: normal spirometry, no bronchodilator response, normal volumes, severe impairment of diffusion capacity Chest CT: diffuse ground glass opacities with bronchiectasis, scattered cysts, c/w NSIP Transthoracic Echocardiogram: Report Summary Transthoracic Echocardiogram Large amount of right to left flow by agitated saline injection Starting on the third beat, dense opacification by the fifth beat Possible visualization entering from right sided pulmonary veins Agitated Saline Study Agitated saline is primarily used to detect right to left shunts. Microbubbles of air persist long enough to opacify the right heart and diffuse into the lungs. Will only appear in the left heart in the presence of a right to left shunt bypassing the lungs. 2
Agitated Saline Study Early passage to the left suggests intra cardiac shunt. Or large pulmonary AVMs Late passage typically suggests extra cardiac shunt, but may still be intra cardiac shunt. Watch for leftward shift of intra atrial septum. Visualize passage through PFO Patient 1 Based on these findings, chest CT was reviewed with evidence of pulmonary AVMs The clinical scenario and physical exam were consistent with Hereditary Hemorrhagic Telangiectasia (Osler Weber Rendu syndrome) Echocardiogram with agitated saline bubble study is considered part of an appropriate work up for pulmonary AVMs in HHT patients. Agitated Saline Study Extremely high sensitivity and negative predictive value for pulmonary AVMs May over represent pulmonary AVMs which are clinically unimportant Grading has been proposed Grade 1: small amount < 20 bubbles Grade 2: incomplete opacification Grade 3: complete opacification 3
Patient 2 71 year old female who presented with an inferior STEMI, acute SOB, and hypotension. Cardiac Cath with complete RCA occlusion and severe mitral regurgitation. IABP and veno arterial ECMO placed emergently to stabilize patient. TEE obtained in the ICU pre op for MVR. Patient 2 The patient has done well with recovery of a significant portion of her LV function. Recovery of function suggests pre clot material or incomplete thrombosis Aortic thrombus has been described in LVAD and veno arterial ECMO patients. Occlusion of coronary artery flow is an emergency Patient 3 75 year old female with a mechanical aortic valve prosthesis who presented with mental status change and fevers; found to have MSSA bacteremia. Due to a history of GI bleeding, TEE was initially deferred at OSH and empiric antibiotics for presumptive infective endocarditis were started. 4
Patient 3 Patient cleared cultures, but had recurrent GI bleeding issues requiring multiple transfusions. Represented with extreme fatigue and ongoing GI bleeding. Transthoracic Echo to reevaluate the valves. Infective Endocarditis TTE is a reasonable screening tool for suspected endocarditis Completely normal valves (morphology and function) on a technically adequate TTE has a strong negative predictive value.* TEE is much more sensitive and far more detailed for in depth assessment Prosthetic valves, Abscess, Embolic Risk, AUIrani WN, Grayburn PA, Afridi ISOA negative transthoracic echocardiogram obviates the need for transesophageal echocardiography in patients with suspected native valve active infective endocarditis. Am J Cardiol. 1996;78(1):101. Patient 4 83 year old female who presented with acute shortness of breath. LE ultrasound revealed extensive right lower extremity DVT CT confirmed saddle embolism Taken to the OR urgently for embolectomy 5
Transthoracic ECHO McConnell s Sign Indicative of RV strain Regional wall motion abnormalities that spare the RV apex Suggestive of acute PE Patient 4 Thrombus was extracted from the main and branch pulmonary arteries as well as the right and left atria. The PFO was sutured closed. No evidence of stroke or other systemic embolization. Post op the right heart demonstrated significantly improved function. Acute Pulmonary Embolism TTE is not indicated to make a diagnosis of PE. However TTE can identify evidence of significant right heart strain in acute PE and help determine the need for acute embolectomy. TEE performed before or during pulmonary embolectomy can identify extrapulmonary thrombi. 25% of patients found to have extrapulonary thrombi by TEE in one review. Surgical care was altered in almost half the cases in which this was identified. 6
Paradoxical Embolization via PFO Direct visualization of paradoxical embolization has been described in a handful of case reports. Although not in the literature, may play a role in decision making for PFO closure. 7