Echo in ischaemic heart disease and Myocardial infarction

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Gerard P. Aurigemma MD
Board Review Course 2017
Echo in Ischemic Heart
Disease and Myocardial
Infarction
Echo and CAD
• Regional wall motion abnormalities at rest may not
be seen until the luminal diameter stenosis exceeds
85%
– with exercise, a coronary lesion of 50% can result in
regional dysfunction
• Echocardiography can overestimate the amount of
ischemic or infarcted myocardium, as wall motion of
adjacent regions may be affected by:
– Tethering
– Disturbance of regional loading conditions
– Stunning
• Wall thickening and motion should be considered
• Regional wall motion abnormalities may occur in the
absence of CAD

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ASE Guidelines 2005
ASE Guidelines 2005

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7
Case #1

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Case #1
Case #1

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Case #2

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Case #2

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15
Diagnostic Role in Acute MI
• Regional wall motion
abnormality
– Occurs within 5-10
beats of acute coronary
ligation
– Rate and amplitude of
endocardial excursion
decreased
– Reduced wall
thickening or wall
thinning

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Which of the following patients has the acute MI?
A B C
1. Patient A
2. Patient B
3. Patient C
4. All of the above
5. None of the above

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What is the diagnosis?
1. LAD territory infarction with a
septal aneurysm
2. LAD ischemia but no aneurysm
3. Volume loaded LV due to left
sided valve disease
4. None of the above
Violent LBBB

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Courtesy Rick
Grimm, Cleveland
Clinic Foundation
G:GPAslides.3
70 year old woman, complains of indigestion
for 1 day then collapse
Admitted to MICU with shock
Fellow is called to do an echo

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G:GPAslides.3
G:GPAslides.3
What can be said with
confidence about this
patient’s diagnosis?
1. She likely has a
large MI
2. She probably has an
RCA occlusion
3. Shock is due to LV
dysfunction
4. This is probably her
first coronary event

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G:GPAslides.3
Papillary muscle rupture
Clinical features
• Rare complication of acute MI
• New systolic murmur and CHF day 3 to 5
post-MI
• Usually (82%) first coronary event in patient
without collateral circulation; 50% 1 vessel
disease
• Often small area of necrosis
• Poor prognosis (90% mortality) and depends
on extent of rupture
G:GPAslides.3
Papillary muscle rupture
• Posteromedial
papillary muscle
6-12x more common
• anterolateral
papillary muscle has
LAD and LCx supply
• Usually single head
rupture
Papillary muscle
head
Papillary muscle
base

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Ventricular Aneurysm
Echocardiographic features
• LV cavity shape distorted
during
diastole and systole
• Wall thin and motion
paradoxical
• Wide-neck typically with neck
diameter = aneurysm diameter
• Hinge points connecting site
with contractile myocardium
may be seen
• Sensitivity of echo: 93 to
100%
• 85 to 95% involve cardiac
apex
• Thrombus present in 34%
Aneurysm Pseudoaneurysm

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G:GPAslides.3
Left ventricular pseudoaneurysm: Clinical
and pathologic features
Myocardial rupture contained
by adherent parietal
pericardium and thrombus
Small, narrow-neck channel
connecting ventricle and
aneurysm sac
Walls of the pseudoaneurysm
composed of pericardium
rather than thin-walled
myocardial scar of true
aneurysm
pseudoaneurysm

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G:GPAslides.3
Right Ventricular Infarction
Commonly accompanies LV inferior MI (25% -33%)
Results from occlusion of RCA proximal to the RV
marginal branches, LCX, or apex of RV from
“wrap-around” LAD
Hemodynamics characterized by disproportionate
elevation of right-sided filling pressures with
reduced cardiac output
EKG: V4R ST
elevation sensitive
and specific