Echo Potpourri Part IV Case, Cases, and More Cases! · 66 year old male Bicuspid Aortic Valve replaced with a St. Jude valve in December, 2009. No significant coronary artery disease

Echo Potpourri Part IV

Case, Cases, and More Cases!

Lorraine Chubet, RDCS

St. Francis Hospital and Medical Center

66 year old male

Bicuspid Aortic Valve replaced with a St. Jude valve in December, 2009.

No significant coronary artery disease

Previous echo done at another hospital prior to valve replacement showed LVH, severe AS, and ejection fraction of 45%.

BP of 150/100 mmHg

Heart rate of 90 bpm

Clear Lungs

Grade 3/6 systolic ejection murmur

Remainder of exam normal

There was mild perivalvular aortic regurgitation

Mild MR, mild TR, no PI.

LVEF estimated 40% to 50%

No intracardiac shunt was detected by contrast study with agitated saline

No LAA thrombus

A Cor-triatriatum was present in the LA

Rare congenital condition where LA is partitioned into 2 chambers by a fibrous tissue (which normally dissolves)

Rarely requires surgical intervention and only when obstructive

If completely obstructive, in newborns it can cause blue baby and is called total anomolous pulmonary venous return

Mollie Boucher BS, RDMS

Student at SFHMC

School of Cardiac Ultrasound

71 year old female arrives at SFH Emergency room

Patient had episode of syncope escalating in patient collapse

BP: 116/73

Temperature 97.4

Sp O2 100%

Pt presents with “LOUD” Murmur

No acute distress

Chest Clear auscultation

No carotid bruits

No Edema

EKG:

Contrast Enhancing Agent

Patient Brought to Cath Lab…

• Left Main Coronary Artery Open

• WMA w/ open Coronary

• Cath Lab

• RCA Open

Y • Hyperkinetic Basal Segment

• Hypokinetic Mid Cavity

Y • Normal Motion in Apex

• Coronary Arteries are open

Y • What Do you Think???

Lets Make Diagnosis #1!

• Acute HF precipitated by sudden

intense, emotional or physical stress

• Apical Ballooning- does this patient?

• Reduced Ejection Fraction

• Mid Wall motion abnormalities

• Preserved basal and apical function

• Symptoms mimic acute coronary

syndrome

• Coronary arteries open

• Variations of Takotsubo

Mid- Ventricular Variant of TC

• Open Coronary Arteries

• Hypokinesis of Mid Ventricle

• Hyperkinesis of Apical & Basal segments

• Several different Mechanisms causing this

variant

• Loss of estrogen, catecholamine,

coronary artery spasm, LVOT

obstruction

KEEP THESE IN MIND!

Pulse – Wave Mapping

• LVOT CW quantified

• Dagger

• AS? LVOT?

• Gradient

~40 mm/hg

Almost 4m/s

• Pt performed

valsalva maneuver

and gradient stayed

the same!

• MR versus LVOT- Catching

obstruction within

• MR not quantified

• Catching the MR with

LVOT envelope!

• Can quantify LAP

• LAP=SB BY

ARM- PEAK

MRJET4V2

• SB= 116

• PEAK MR JET ~

4.5 M/S

• LAP= 35mm/hg

• MR Increases

LAP

We KNOW- MR

result of SAM

ECHO REPORT:

• DECREASED EF 25-35%

• Moderate Mitral Regurgitation

• LA Volume index is normal

• Dynamic subvalvular LVOT

obstruction 40 mm/hg gradient

• With Valsalva 41 mm/hg Gradient

• Normal Right ventricular function

• TR peak Gradient 18.3 mm/hg

Dynamic

outflow

obstruction

40 mm/hg

subaortic

pressure

gradient

PW

doppler

througho

ut LV

Treatment

Hospitalized

until LV

function

restored

Hospitalized until LV function restored

Beta Blockers, ACE inhibitors for heart

muscle recovery

Anti-Anxiety medication- prevent release of stress

hormones

Patient presents with nausea and vomiting for 4 days

Previous chest discomfort 6 days prior

Cardiogenic shock blood pressure 73/52

What is the RVSP?

Wait don’t we already have all the information

Blood Pressure 73/52

TR Jet estimated RVSP was 41 mmHg

Admitted Sunday, January 12, 2014 to St. Francis Hospital ED

Male

61 years old

Flu-like symptoms for the last two weeks, which consisted of fever, cough and nausea

Extremely fatigue for the past two days prior to admission at St. Francis Hospital, along with weakness and dyspnea upon exertion

Inferior wall ST elevation

Decompensated CHF

Holosystolic murmur

Works in construction/home remodeling

Smokes two packs of cigarettes/day for the last 45 years

His father had a MI at 65 years old

The first echo was done on Sunday, January 12, 2014

It was a STAT echo, completed by a fellow

What do you see?

Size and function of chambers?

What do you see?

Regurgitation? If so, where

and how much?

What do you see?

What do you think of the

wall function?

Ejection Fraction?

What do you think about

the color flow?

What do you think might

be happening?

What do you see?

Size and function of the

chambers?

Regurgitation? If so, where and

how much?

Regurgitation? If so, where and

how much?

Ventricular Septal Defect (VSD) Muscular (Trabecular) – 2nd most common in

adults

Wall Abnormalities (MI occurred) Severe hypokinesis of inferior and infero-septal

walls

Mild LVH and RVH

Dilated RA

Mild MR (+ some MV thickening)

Mild to moderate TR (+ some TV thickening)

Reduced right ventricular global systolic function

40% EF

CATH OF LV

What do

you see?

Cath showed occlusion of RCA, You can also see both sides of the heart fill with dye, which confirms that there is a VSD

This makes sense, since the patient experienced a MI and VSD

SIDENOTE: The Cath was actually done FIRST, but for the sake of the presentation

Operation to repair the muscular VSD was done on Monday, January 13, 2014, which was one day after echo findings Hemashield graft was seated and sutured

Pacing wires were placed in the right atrium and right ventricle to help control abnormal heart rhythms like A-Fib and tachycardia

TEE was performed in the OR to check on VSD; it was confirmed that there was no residual VSD

Patient was discharged on Friday, January 17, 2014

Patient was given: Aspirin – Relieves pain and is an anti-inflammatory

Statin – Lowers cholesterol

Beta blockade – Usually given after MI and to prevent another MI from occurring

ACE inhibitor - Treatment of hypertension (elevated blood pressure) and congestive heart failure. Lowers BP

Patient was re-admitted on Sunday, January 19, 2014, just two days after hospital discharge

Now present with:

Acute respiratory failure

Severe pulmonary edema

Cardiogenic shock

Tachycardia

The second echo was done on day of re-admission

It was a STAT echo

By Hadley Santos BS, RCS

What do you

see?

Size and

function of

chambers?

What do you see?

Regurgitation? If so, where and

how much?

What do you see?

What do you think of the

wall function?

What do you see?

Size and function of

chambers?

Size and function of chambers?

Regurgitation? If so, where and

how much?

What do you think of the envelope?

What is the severity?

What do you see?

Size and function of chambers?

Regurgitation? If so, where

and how much?

TR Peak Gradient = 56.8 mmHg

Right Ventricular Systolic Pressure = 66.8 mmHg

?

What do you see?

Ejection Fraction?

What view is this?

What do you see?

Regurgitation? If so, where

and how much?

Improvements?

Ruptured posterior papillary muscle with flail posterior MV leaflet

Wall Abnormalities (from MI) Inferior hypokinesis

Repaired muscular VSD

Right/left pleural effusion

Severely dilated LA

Mild LVH and RVH

High pulmonary artery pressure of 66.8 mmHg, which is considered “moderate” almost severe *not pictured

Severe MR

Moderate AI and TR

60% EF (increased since Echo #1)

Immediate admission to the operating room

The posterior papillary muscle was removed

The mitral valve was replaced with a bio-prosthetic valve

A follow up echo was done on Thursday, January 23, 2014

Completed by Lynsy Friend BS, RCS, FASE

What do you see?

Size and function of the

chambers?

What view is this?

What do you see?

Regurgitation? If so, where

and how much?

What do you think?

Size and function of

chambers?

What do you see?

Regurgitation? If so,

where and how much?

What do you see?

Size and function?

Ejection fraction?

New bio-prosthetic mitral valve Wall Abnormalities (MI)

Inferior hypokinesis

Minimal anterior pericardial effusion Significant pleural effusion (not visualized in the clips

I provided) Mildly dilated LA Normal RA size Mild LVH Moderate pulmonary artery pressure at 45.3 mmHg

(decreased since Echo #2) *not pictured Some MR (+ some MV thickening) Moderate TR (+ some TV thickening) Mild AI ( + some AV thickening) 20-30% EF (decreased since Echo #3)

29 y/o white female

Fibromyalgia

Vascular necrosis of lower extremities

Chronic pancreatitis

Systemic Lupus Erythematosus

Bilateral total hip replacement

Splenectomy

No tobacco use

No family history of CAD

MDs charted in past hospital visits that pt was a “drug seeker”

Female age 40

Immigrated from El Salvador at age 18

Developed abdominal pain, diarrhea, nausea, vomiting

Unable to walk more >3 steps at a time due to exertional CP and SOB

Labs: Eosinophils 17% (reference range 0-7%)

1+ RV lift and palpable P2

Second heart sound widely split during inspiration with an increased pulmonic component 3+/4+ intensity

Soft 1/6 diastolic decrescendo murmur, high pitched quality, at the left sternal border

JVP not elevated

Mayo Clinic Apical 4 Chamber

Mayo Clinic Apical 4 Chamber

Mayo Clinic Apical 4 Chamber

Mayo Clinic Apical 4 Chamber

1. LV non-compaction

2. Apical hypertrophic cardiomyopathy

3. LV and RV thrombus

4. Something else

Findings consistent with hypereosinophilic syndrome

Large laminated thrombus occupies apical 2/3 of LV cavity. Small apical RV thrombus.

Mild LVE, EF 49%, Grade 3/4 diastolic dysfunction

Thickened MV and TV without subvalvular thrombotic involvement or leaflet tethering. Mild MR and TR.

Large LV thrombus

Diffuse subendocardial delayed enhancement of LV and RV

LVEF 48%

Tiny pericardial effusion

Findings suggestive of eosinophilic myocarditis secondary to a parasitic infection

Extensive excision of fibrosis and organized thrombus in LV and RV cavities. Substantially improved both cavity sizes

Posterior mitral valve also appeared involved with moderate regurgitation

S/P 29- mm St. Jude mitral valve replacement, normal prosthetic function

Normal LV size, EF 60%

Small area of endocardial fibrosis at LV and RV apex

No new intracavitary thrombi

RVSP has decreased

Normal MV prosthetic function

Marked endocardial fibrosis with organizing degenerating mural thrombus, encasing tendinous chords and extending to MV and into myocardium

Patient is feeling well other than overall feeling of weakness

No shortness of breath, chest pain or congestive heart failure symptoms

Follow up again in six months

Happy Mother’s Day to all the Mothers.

Safe Travels Home

Hope to see you all next year