Bethannie Dziuk 2017

Understanding  Echo  Lingo  

 

 

 

 

 

 

 

Brief  Review:  

• Echocardiography  can  evaluate  the  cardiac  function  and  structure  with  images  produced  by  ultrasound1  o Can  assess  chamber  size,  function,  and  wall  thickness  

• Procedure  of  choice  for  diagnosis  and  evaluation  of  cardiac  conditions:  valvular  abnormalities,  intracardiac  thrombi,  pericardial  effusions,  and  congenital  abnormalities  

• Transthoracic  echocardiography  (TTE)  vs  transesophageal  echocardiography  (TEE)    o TTE:  ultrasound  transducer  is  placed  on  the  anterior  chest  wall  à  non-­‐invasive  o TEE:  ultrasound  transducer  is  placed  in  the  esophagus  à  invasive,  provides  clearer,  more  detailed  images    

 

        The  Lingo:  

Cardiac  Remodeling3:  

• Manifest  as  changes  in  cardiac  size,  shape,  and  function    o Can  occur  after  conditions:  MI,  inflammatory  myocardial  disease,  volume  overload,  dilated  

cardiomyopathy  (enlarged/  weakened  left  ventricle)  3  § Because  the  heart  has  to  work  harder,  this  causes  a  hypertrophic  response  à  

hypertrophy  has  been  associated  with  increased  interstitial  fibrosis,  cell  death  and  cardiac  dysfunction4  

• 1.  Hypertrophy:  enlargement  of  the  heart  4  o Causes:  volume  overload  (ex:  HF)  HTN,  valvular  heart  disease,  CAD,  ischemia  

 

• Eccentric:  (TIP:  eccentric  –  enlarged  chamber)    o No  or  small  change  in  wall  thickness  with  an  increase  in  chamber  volume  o Mechanism:  new  sarcomeres  are  added  in-­‐series  to  existing  sarcomeres  (Recap:  they  

are  increasing  in  length  so  the  chamber  gets  larger)  o Common  causes:  ischemia    

• Concentric:  (TIP:  concentric  –  looks  like  a  concave  mirror)  o Increase  in  wall  thickness  with  no  change  or  slight  reduction  in  chamber  volume4  o Mechanism:  new  sarcomeres  are  added  in-­‐parallel  to  existing  sarcomeres  =  increase  

in  wall  thickness3  (Recap:  they  are  added  next  to  each  other  to  increase  size)  o Common  causes:  HTN,  aortic  stenosis  

 

 

Example  1:  Patient  X’s  Transthoracic  Echo  Report:  

Conclusions:  

  Four-­‐chamber  dilation.  LV  wall  thickness  is  normal,  eccentric  left  ventricular  hypertrophy.  Wall  motion  shows  akinesis  of  the  septum,  and  anterior  wall  severe  hypokinesis  elsewhere.    No  LV  thrombus  seen  on  contrast-­‐enhanced  images.  Severely  depressed  systolic  function  with  LVEF  of  15-­‐20%.  Diastolic  function  not  able  to  be  assessed.    

Valves  are  normal  in  structure  and  function.  Trace  AR  and  PR,  mild  MR  and  TR.  The  calculated  PASP  is  39mmHg  with  an  estimated  RA  pressure  of  15  mmHg.  Trivial  posterior  pericardial  effusion,  no  hemodynamic  compromise.  No  prior  study  for  comparison.  

Back  to  the  Case:  LV  wall  thickness  is  normal,  eccentric  left  ventricular  hypertrophy  

 

1. Hypertrophy  2. Left  ventricular  

Systolic  Function  3. Left  ventricular  

Diastolic  Function  4. Wall  Motion  5. Valves    6. Thrombosis/Mass  

Figure  1:  Cardiac  Hypertrophy11  

Bethannie Dziuk 2017

 

2.  Left  Ventricular  Systolic  Function  (Ejection  Fraction)2:  

• Percentage  of  blood  ejected  with  each  contraction  of  the  left  ventricle    

• ‘Normal’:  LVEF  >  55%  o LVEF  <  40%  =  HFrEF  à  Systolic:  contractility  and  

ejection  are  reduced    

 

 

3.  Left  ventricular  diastolic  function  • Looking  for  signs  of  impaired  LV  relaxation,  reduced  

restoring  forces,  and  increased  diastolic  stiffness  • Pulmonary  capillary  wedge  pressure  (PCWP):  indirect  estimate  of  LV  diastolic  pressure  • Report  should  comment  on  LV  filling  pressure  and  the  grade  of  LV  diastolic  

function  o LVEF  >  40%  =  HFpEF  à  Diastolic:  stiffening  and  loss  or  adequate  

relaxation  • Pulmonary  arterial  systolic  pressure  (PASP):  assessment  of  pulmonary  

HTN13  o Normal  PASP  <35mmHg  

§ TIP:  When  >  35mmHg,  pulmonary  HTN  should  be  considered  

 

4.    Wall  Motion:    

• American  Society  of  Echocardiography  standardized  reporting  using  a  17-­‐segment  model.  Scores  are  assigned  to  different  segments  and  then  added  together  to  get  total  wall  motion  score.5  o Hyperkinesia:  increased  movement  o Normokinesia:  normal  movement    o Hypokinesia:  reduced  movement  o Akinsia:  absence  of  movement  o Dyskinesia:  dyscronization  

• Wall  motion  abnormalities  are  most  commonly  caused  from  MI  or  severe  ischemia.  This  reduces  the  LV  pump  function5  • The  image  below  is  reported  in  the  patient’s  echo:    

 

 

Back  to  the  Case:  Severely  depressed  systolic  function  with  LVEF  of  15-­‐20%.  Diastolic  function  not  able  to  be  assessed.  

Figure  2:  Cardiac  Remodeling  Comparison12    

Figure  415:  Patient  X’s  Assessment  of  Wall  Motion  

Back  to  the  Case:  Wall  motion  shows  akinesis  of  the  septum,  and  anterior  wall  severe  hypokinesis  elsewhere  

Bethannie Dziuk 2017

 

5.  Valves:  

• Can  identify:  Valvular  regurgitation  or  Vavular  stenosis9  o Valvular  regurgitation:  presence  of  backward  flow  across  a  given  

closed  cardiac  valve.  Regurgitation  creates  a  volume  overload  state9  § Aortic  regurgitation  (AR)  § Pulmonary  regurgitation  (PR)  § Mitrial  Regurgitation  (MR)  § Tricuspid  Regurgitation  (TR)  

 

 

 

 

6.  Mass  or  thrombi  

• Embolism  from  the  heart  or  aorta  can  lead  to  TIA,  stroke,  or  occlusion  of  peripheral  arteries10  

 

Recommended  Guidelines:  European  Association  of  Echocardiography  and  American  Society  of  Echocardiography  

References:    1. Lange  RA,  Hillis  L.  eChapter  13.  Cardiovascular  Testing.  In:  DiPiro  JT,  Talbert  RL,  Yee  GC,  Matzke  GR,  Wells  BG,  Posey  L.  eds.  Pharmacotherapy:  

A  Pathophysiologic  Approach,  9e.  New  York,  NY:  McGraw-­‐Hill;  2014.  2. Di  Carli  MF,  Kwong  RY,  Solomon  SD.  Noninvasive  Cardiac  Imaging:  Echocardiography,  Nuclear  Cardiology,  and  Magnetic  Resonance/Computed  

Tomography  Imaging.  In:  Kasper  D,  Fauci  A,  Hauser  S,  Longo  D,  Jameson  J,  Loscalzo  J.  eds.  Harrison's  Principles  of  Internal  Medicine,  19e.  New  York,  NY:  McGraw-­‐Hill;  2015.  

3. Mihl  C,  Dassen  WRM,  Kuipers  H.  Cardiac  remodelling:  concentric  versus  eccentric  hypertrophy  in  strength  and  endurance  athletes.  Netherlands  Heart  Journal.  2008;16(4):129-­‐133.  

4. Hou  J,  Kang  YJ.  Regression  of  Pathological  Cardiac  Hypertrophy:  Signaling  Pathways  and  Therapeutic  Targets.  Pharmacology  &  therapeutics.  2012;135(3):337-­‐354.  doi:10.1016/j.pharmthera.2012.06.006.  

5. Johnson  Francis.  Regional  wall  motion  abnormalities  in  coronary  artery  disease.  Cardiophile.  2009  6. Palmieri    V,  Okin  PM,  Bella  JN  ,  et.  al.  Echocardiographic  wall  motion  abnormalities  in  hypertensive  patients  with  electrocardiographic  left  

ventricular  hypertrophy.  Hypertension.  2003;41:75-­‐82,  originally  published  January  1,  2003  7. Nagueh,  SF,  Smiseth  OA,  Appleton,  CP.  Recommendations  for  the  evaluation  of  left  ventricular  diastolic  function  by  echocardiography:  an  

update  from  the  american  society  of  echocardiography  and  the  european  association  of  cardiovascular  imaging.  mJ  Am  Soc  Echocardiogr  2016;29:277-­‐314  

8. Nagueh,  SF,  Smiseth  OA,  Appleton,  CP.  Recommendations  for  the  evaluation  of  left  ventricular  diastolic  function  by  echocardiography.  .mJ  Am  Soc  Echocardiogr  2016;29:277-­‐314  

9. Lancellotti  P,  Tribouilloy,  Haendorff  A,  European  association  of  echocardiography  recommendations  for  the  assessment  of  vavlular  regurgitation  part  1  aortic  and  pulmonary  regurgitation  (native  valve  disease.  European  Journal  of  Echocardiography  (2010)11,223-­‐244.  

10. Saric  M,  Arnour  AC,  Arnaout  MS,  et.  al.  Guidelines  for  the  use  of  echocardiography  in  evaluation  of  cardiac  course  of  embolism.    Journal  of  the  American  Society  of  Echocardiography.    

11. Merlos  P,  Núñez  J,  Sanchis  J,,  et  al.  “Echocardiographic  Estimation  of  Pulmonary  Arterial  Systolic  Pressure  in  Acute  Heart  Failure.  Prognostic  Implications.”  European  Journal  of  Internal  Medicine  24,  no.  6  (September  2013):  562–67.  

Pictures:  12. Maladaptive  cardiac  hypertrophy:  Concentric  and  eccentric  hypertrophy,  compared  to  a  normal  heart.  Adapted  from  Katz,  Physiology  of  the  

Heart  (3rd  ed),  2001.  13. Synder,  SR,  Kivlehan  SM,  Kevin  Collopy  et  al.  Diagnosis  and  treatment  of  the  patient  with  heart  failure.  EMS  World.  Mar  2015.  14. Heart  Valve  Problems  Guide:  Causes,  Symptoms  and  Treatment  Options.  https://www.drugs.com/health-­‐guide/heart-­‐valve-­‐problems.html  15. Image  obtained  from:  https://www.google.com/search?q=echocardiography+summary+wall+motion+figures&client=safari&hl=en-­‐

us&prmd=isvn&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjJpJzPoM_RAhVkr1QKHVxRDksQ_AUIBygB&biw=768&bih=905#imgrc=GQ6ZzkhK6Wsg4M%3A  

Back  to  the  patient  case:  No  LV  thrombus  seen  on  contrast-­‐enhanced  images  

Back  to  the  Case:  Valves  are  normal  in  structure  and  function.  Trace  AR  and  PR,  mild  MR  and  TR.  

Figure  4:  Valves13