Transcript Focused Echocardiographic Examination in the Emergency

Ronald E. Cuyco, MD, FPCC
Emergency Echocardiography
Advantages of echocardiography as a diagnostic tool in
the emergency room and in the ICU:
Safe and tolerable
Easily reproducible
Readily available (portability)
Relatively low-cost
No radiation
Emergency Echocardiography
What emergency situations should be assessed?
 Acute chest pains
 Acute dyspnea
 Hemodynamic instability (hypotension/shock)
 New murmur
 Chest trauma
 Cardiac sources of embolism
 Cardiac arrest/CPR
ESC Congress 2011
Emergency Echocardiography
Where can emergency echocardiography be performed?
 Emergency room
 CCU –Coronary Care Unit
 ICU/cardiac ICU – Intensive Care Unit
 Operating room
 Cardiac catheterization laboratory
 Bedside
 Ambulance (hand-held echocardiography)
 Outside of the hospital
ESC Congress 2011
Emergency Echocardiography
Philippine Heart Center Echocardiograpy Census (2011)
Total In-patient Echo
Bedside Echo (ER and ICU)
Intra-operative TEE (IOTEE)
4,407
1,110 (25%)
221 ( 5%)
Top 3 indications for emergency echocardiography:
 Chest pains
 Dyspnea
 Hypotension
Emergency Echocardiography
Acute chest pains and dyspnea
 Acute myocardial ischemia or infarction
 Aortic dissection
 Pulmonary embolism
Emergency Echocardiography:
Aortic Dissection
TTE findings associated with aortic dissection
 Aortic insufficiency
 Enlarged aortic root (>3.5 cm at annulus or sinotubular junction)
 Presence of pericardial effusion
 Infero-posterior wall motion abnormality (RCA
territory)
Emergency Echocardiography
Aortic Dissection
 May require TEE to visualize distal ascending aorta,
transverse and descending aorta
 Intimal flap seen on TTE would clinch a diagnosis of
aortic dissection
 Lack of definite signs on TTE/TEE does not exclude an
aortic dissection, CLINICAL DATA still important
Echo: Aortic dissection
Suprasternal view of aorta showing the intimal flap
Color flow doppler within the false and true lumen
Cardiac CT-MRI: Aortic Dissection
- Complimentary tools to emergency
echocardiography to rule-in or rule-out aortic
dissection
- Cardiovascular CT-MRI “triple rule-out” capability
is an advantage over other modalities
- Disadvantages: not readily available, non-portable,
expensive, and requires highly skilled technician
and staff
Emergency Echocardiography:
Acute Coronary Syndrome
 Wall thickening abnormalities
 Evidence of ruptured interventricular
septum, LV free wall or papillary muscle
 LV systolic and diastolic functions
 Cardiac filling pressures
 Pulmonary pressure
Acute myocardial infarction with
Ruptured Ventricular Septum
4-chamber view showing the echo drop-out
space across the IV septum
Color flow doppler demonstrating mosaic flow
across the septal defect
LV systolic function
 LV systolic function is not just EF!
 Fractional shortening
 Stroke volume
 Cardiac index
 Systolic tissue velocity of the mitral annulus and
myocardium
 Strain
 Regional wall motion
Stroke volume
Simpson’s rule
M-Mode
Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography Guidelines
and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the
European Association of Echocardiography, a Branch of the European Society of Cardiology
Systolic tissue Doppler velocity in normal and
abnormal
Normal
Sm = 12 cm/sec
Abnormal
Sm = 6 cm/sec
Khouri et al, JASE, March 2004
Doppler Tissue Imaging (DTI)
 E/Ea ratio – correlates well
with LV filling pressure
 E/Ea ratio > 15
 Highly specific for elevated LA
pressure
 E/Ea < 8
 Sensitive for normal LA
pressure
Khouri et al, JASE March 2004
E/Ea ratio < 10
- PCWP < 15 mmHg
E/Ea ratio > 15
- PCWP > 20 mmHg
Nagueh et al. Circulation. 2000
Doppler Assessment of LV filling
pressures in patients with AF
Method
Cut-off
Accuracy
E wave Deceleration time
< 120 ms
Sens/Spec 100%/96% in
predicting PAOP > 20
mmHg
Isovolumic relaxation
time
< 65 ms
Sens/Spec 72%/82% in
predicting PAOP of > 15
mmHg
E/Ea ratio
> 11
Sens/Spec 75%/93% in
predicting PAOP of >15
mmHg
E/Vp
> 1.4
Sens/Spec 72%/100% in
predicting a PAOP of > 15
mmHg
Hemodynamic monitoring using Echo, De Backer, 2011
Measurement of pulmonary artery
pressure
Pulmonary Hypertension
Emergency Echocardiography:
RV systolic overload
 Elevated right ventricular afterload leading to
pulmonary hypertension and right heart failure
 Echocardiographic features:
1. Dilated pulmonary artery, right ventricle and right
atrium
2. Hypokinetic right ventricle
3. Moderate to severe TR with elevated pulmonary
systolic arterial pressure
4. Systolic septal flattening
5. No significant left heart abnormality
Pulmonary artery mass
Parasternal short-axis view at the AV level showing the
mobile echogenic density within the pulmonary artery
Apical 4-chamber view
RVEF by 3D Echocardiography
Full-volume reconstruction of the right ventricle with
EF computation
ER Echocardiography: Chest
Trauma
Echocardiographic findings to look for:
 Rupture of cardiac structures (valves and myocardium)
 Myocardial contusion (RWMA of the anterior rightsided structures)
 Pericardial effusion
 Aortic rupture or intimal tear (TEE maybe useful if not
contraindicated)
 Ruptured coronary sinus of Valsalva
Traumatic RCSOV
 Ruptured coronary sinus of valsalva due to stabbing
TEE with color flow doppler demonstrating the mosaic
color flow across the rupture site
Assessment of volume status and
responsiveness to fluid challenge
 Hypotensive or patients in circulatory shock due to
hypovelemia or sepsis
 IVC diameter could be a good estimate of CVP
 SVC and IVC diameter changes in ventilated patients
can predict patients’ fluid responsiveness
 Respiratory changes in aortic blood flow VTI separate
responders from non-responder patients to fluid
challenge
Assessment of volume status
 CVP can be estimated by the size of IVC
EXPIRATI
INSPIRAT
IVC is virtually collapsed during inspiration
Hemodynamic monitoring using Echo, De Backer, 2011
IVC diameter changes during
mechanical ventilation
ins
exp
Collapsibility index can be calculated by
measuring the largest and smallest diameters
Hemodynamic monitoring using Echo, De Backer, 2011
SVC collapsibility in ventilated
patients
No change during mechanical
insufflation
Large diameter changes during
mechanical insufflation indicate a
responder patient to fluid challenge
Hemodynamic monitoring using Echo, De Backer, 2011
Response to fluid challenge: Stroke
volume monitoring
500 ml
infused
SV 65 ml
Hemodynamic monitoring using Echo,
De Backer, 2011
SV 38 ml
Cardiac volume and filling
pressures
70 ml
65 ml
38 ml
Restriction to
filling
Abnormal
relaxation
Normalized
profile
Hemodynamic monitoring using
Echo, De Backer, 2011
Emergency Echocardiography
Transthoracic or Transesophageal Echocardiography ?
 TTE should be the first-line diagnotic procedure over
TEE due to its versatility, availability and tolerance.
 TEE is the procedure of choice in the assessment of
circulatory failure complicating peri-operative
course.
 TEE is needed when TTE image quality is inadequate
as in ventilated patients, COPD and obese patients.
Myocardial Contrast Echocardiography
in the ER and ICU settings
3D echo for LV analysis
Full-volume reconstruction of the LV with EF computation
Summary
Echocardiographic examination in the emergency
room can facilitate prompt diagnosis of aortic
pathology, pulmonary embolism, myocardial
ischemia or infarction and its complication, as well
as unexplained hypotension.
2. Echocardiography remains an important diagnostic
tool in the evaluation of patients with circulatory or
respiratory failure in critical care setting.
1.
3. In ICU setting, echocardiography plays an essential
role in ensuring prompt and correct diagnosis, as
well as in hemodynamic monitoring.
4. Application of new technological advances like
myocardial contrast echocardiography, tissue
Doppler imaging and 3D echocardiography
improves the capabilities of echocardiography in
emergency and critical care settings.
Thank you
RV systolic function assessment
 Visual inspection of RV free-wall motion and tricuspid




annulus motion
TAPSE
Tissue Doppler imaging
RV fractional area change
RV ejection fraction by 3D echo
Aortic blood flow respiratory
variation
INSPIRATION EXPIRATION
Large respiratory change indicates positive response to fluid
infusion
Hemodynamic monitoring using Echo, De Backer, 2011
Emergency Echocardiography
Unexplained hypotension, syncope and arrhythmia
 Pericardial effusion with tamponade
 Hypovolemia/ sepsis
 Segmental or global hypokinesia with depressed
systolic function
 Aortic stenosis
 Hypertrophic obstructive cardiomyopathy
Assessment of LV filling pressure
Tissue Doppler (Ea)
Color M-mode Vp
Massive pericardial effusion
Parasternal short-axis view at the mid-LV level
showing the pericardial effusion
Apical 4-chamber view showing the pericardial
effusion
3D Echocardiography in the
Emergency Room
 Accurate and reproducible ventricular function
assessment (LV and RV) – volume and ejection
fraction
 Assessment of valvular pathology
RAP as estimated by IVC size
RAP (mmHg)
IVC size (cm)
IVC contraction
(inspiration %)
Hepatic vein
0–5
< 20
> 50
Normal
10
< 20
< 50
Normal
15
> 20
< 50
Normal
20
> 20
< 50
Dilated
Measurement of Pulmonary
Arterial Pressure
PASP = 4 X (TR jet velocity)2 + RAP
PAEDP = 4 X (PR jet end-diastolic velocity)2 +RAP
Mean PAP = 4 X (PR jet peak velocity)2
or 80 – RVOT AT/2
Responsiveness to Fluid Challenge
Parameters to monitor:
 IVC diameter change on ventilator insufflation (TTE)
 SVC diameter change on ventilator insufflation (TEE)
 Aortic blood flow respiratory variation
dP/dt using MR jet
Left Ventricular Volume (M-mode)
Stroke volume (SV) = LVEDV – LVESV
Cardiac Output (CO) = SV x HR
1000
Cardiac Index (CI) = C O
BSA
Where:
LVEDV= end diastolic volume
LVESV= end systolic volume
HR = heart rate
1000 = conversion of cc to liters
BSA = body surface area
Doppler Evaluation of LV Systolic
Function
Critical Care Echocardiography
 Echocardiography is best suited for the evaluation of
unstable patients in the ICU due to its versatility,
safety and capability of providing instantaneous
diagnosis
 Echocardiography is especially requested for the
assessment of circulatory failure and shock
Critical Care Echocardiography:
Indications
Circulatory failure (hypotension and shock)
eg. Complicated MI, pulmonary embolism, cardiac
tamponade
2. Cardiac arrest (during or after successful
resuscitation)
3. Respiratory failure
eg. Cardiogenic pulmonary edema vs ARDS
4. Other clinical settings like chest trauma, infective
endocarditis and cardioembolic phenomena
1.
Focused Echocardiography in
Critical Care
 Basic ventricular dysfunction assessment (RV and LV)
 Volume status assessment and response to fluid




challenge
Assessment of cardiac filling pressures
Measurement of cardiac output and pulmonary artery
pressure
Assessment of valve pathology and pericardial
tamponade
Echocardiographic evaluation in life support
Emergency Echocardiography
Accurate management of chest pains in the emergency
room requires knowledge of the differential diagnosis
and an appropriate use of diagnostic tools.
Emergency Echocardiography:
Acute Chest Pains
Other causes of regional wall motion abnormality aside
from acute myocardial ischemia:
 Prior myocardial infarction
 Focal myocarditis
 Prior surgery
 Right ventricular overload
 Left bundle branch block
 WPW-ventricular pre-excitation
 Cardiomyopathy
 Paced rhythm
Emergency Echocardiography
Focused peri-resuscitation and critical echocardiography
pp33 and 35 ESC guideline
Myocardial Contrast
Echocardiography