The single most useful diagnostic test in the evaluation of patients with HF is the comprehensive 2-dimensional echocardiogram coupled withDoppler flow studies to determine whether abnor-malities of myocardium, heart valves, or pericardi-um are present and which chambers are involved. Three fundamental questions must be addressed: (1) is the LVEF preserved or reduced, (2) is the struc-ture of the LV normal or abnormal, and (3) are there other structural abnormalities such as valvular, peri-cardial, or right ventricular abnormalities that could account for the clinical presentation? This informa-tion should be quantified with a numerical estimate of EF, measurement of ventricular dimensions and/or volumes, measurement of wall thickness, and evaluation of chamber geometry and regional wall motion.
Basic Echocardiography Selwyn Wong Middlemore Hospital
Echocardiography Basics Ultrasound waves sent from chest wall
Left ventricle - systolic function Ejection fraction (%) Normal >55 Mild 40-50 Moderate 30-40 Moderate-severe 20-30 Severe <20
Part One A 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily. On examination she has a pulse rate of 80/minute, blood pressure of 125/70 mmHg and a jugular venous pressure (JVP) of +1 cm. She has a soft systolic murmur with no added sounds, her chest is clear and she has no oedema. An ECG shows sinus rhythm. A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15.5/28 but no pulmonary congestion. Echocardiography demonstrates systolic dysfunction with fractional shortening of 18% and mild mitral regurgitation. Her serum creatinine level is normal. Which of the following is the most appropriate next step in treatment? A. Increase the frusemide dose. B. Add digoxin. C. Add an aldosterone antagonist. D. Add an angiotensin II receptor antagonist. E. Add a beta blocker.
Left ventricle - diastolic function Mitral inflow Pulmonary veins Mitral TVI
AR - LV Response <ul><li>Chronic AR - decompensated LV </li></ul><ul><li>LVEF<55%, LVESD>55mm, LVESV 60ml/m2 </li></ul>
Part One A patient with aortic regurgitation has the following haemodynamic measurements: cardiac output (CO) 7.5 L/minute heart rate (HR) 75/minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat. The regurgitant fraction in this patient is: A. 25%. B. 33%. C. 50%. D. 67%. E. 75%.
Part One A 45-year-old asymptomatic man returns for follow-up. He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve. He has never had endocarditis. Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement? Key: LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) / LVEDD LA Left atrial E. D. C. B. A. 55 0.35 75 50 0.45 65 45 0.25 70 40 0.40 75 60 0.30 70 LA size (mm) [<40] FS [0.30-0.40] LVEDD (mm)[35-55]
MR- Quantification of LV contractility <ul><li>LV systolic function - most important parameter </li></ul><ul><li>Ejection fraction, fractional shortening, velocity of circumferential fibre shortening - load dependent </li></ul><ul><li>MR allows supranormal values of EF etc. </li></ul><ul><li>Early systolic dysfunction if; </li></ul><ul><ul><li>EF < 60% (severe MR) </li></ul></ul><ul><ul><li>ES diameter < 45mm (26mm/m2) </li></ul></ul>
Part One A 35-year-old woman has increasing breathlessness on exertion. Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm. The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following? A. Severe pulmonary hypertension (cor pulmonale). B. Aortic stenosis. C. Mitral regurgitation. D. Mitral stenosis. E. Aortic regurgitation.
Part One A 28-year-old woman, who emigrated from Cambodia 10 years ago, presents to the emergency department with a three-week history of increasing shortness of breath, orthopnoea, nocturnal dyspnoea and ankle oedema. She is 25 weeks pregnant and has no significant past medical history. The presence of pulmonary oedema is confirmed clinically and radiologically. She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood pressure is 125/85 mmHg. Echocardiography demonstrates mitral stenosis with an estimated valve area of 1.3 cm2 and a left atrial diameter of 50 mm [<40 mm]. There are no other abnormalities. What is the most appropriate next step in management? A. Balloon valvotomy. B. Surgical valvotomy. C. Digoxin therapy. D. Beta-blocker therapy. E. Angiotensin converting enzyme (ACE) inhibitor therapy.
Part One A 55-year-old man presents with acute pulmonary oedema. Five years earlier, he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St. Jude) for mixed mitral valve disease. He has been well with normal exercise tolerance prior to the day of admission. Examination on admission reveals tachypnoea, sinus tachycardia of 110/minute, blood pressure of 105/60 mmHg, elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields. His prothrombin time−international normalised ratio (PT-INR) is 1.9 [desired therapeutic range 2.0-3.5]. Serum urea, creatinine and electrolytes are normal. The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed. Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metres/second). What is the most appropriate course of action? A. Administration of intravenous streptokinase. B. Administration of intravenous heparin. C. Administration of intravenous antibiotics. D. Addition of an antiplatelet agent. E. Immediate mitral valve replacement. .
Estimation of Pulmonary Pressure PA systolic pressure <ul><li>Tricuspid regurgitation jet velocity </li></ul>
Estimation of Pulmonary Pressure RA pressure <ul><li>IVC size </li></ul>
Part One The severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation. This method uses the Bernoulli equation which states that P = 4v2 (where P = instantaneous pressure gradient and v = velocity across the valve). There is tricuspid regurgitation with a peak velocity of 4 metres/second and a mean velocity of 3.5 metres/second. Assuming right atrial pressure is 5 mmHg, the best estimate of the peak right ventricular systolic pressure (± 2 mmHg) is: A. 50 mmHg. B. 55 mmHg. C. 60 mmHg. D. 65 mmHg. E. 70 mmHg.
Part One A 65-year-old woman presents with a one-week history of progressive dyspnoea. On admission, there are signs of shock, a systolic murmur and an elevated jugular venous pressure. The ECG shows sinus tachycardia but no other abnormality. An antero-posterior chest X-ray shows cardiomegaly. The serum troponin I level is 0.5 mg/L [<0.1]. A computed tomography (CT) scan is shown below. What is the most likely diagnosis? A. Pulmonary embolism. B. Right ventricular infarction. C. Pericardial tamponade. D. Myocarditis. E. Acute mitral regurgitation.
Endocarditis Positive echocardiogram for IE Discrete, echogenic, oscillating intracardiac mass located at a site of endocardial injury (e.g., on a valve or supporting structure, in pathway of regurgitant jet, or site of implanted material), or Periannular abscess, or New dehiscence of a prosthetic valve