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Echo Quiz

Echo Quiz 1
EKG Quiz 2
Case 1
• Mr. TGH is a 46 yr old man with recent Inf. Wall STEMI and
S/P PTCA with BMS was admitted back to the hospital in a
week with shortness of breath and leg swelling.

• VS: T 98
• P 96
• BP 110/56
• RR 18 with 99% sats

• Physical exam is unremarkable except for pitting leg edema.


• EKG and 2 D Echo was ordered as part of the workup.

• Findings:
Pseudoaneurysm
• It is a rupture of the myocardial free wall
that is contained by pericardial adhesions.
• It has a narrow neck and is devoid of
myocardium in the walls.

• Pseudo-false aneurysm is when the wall contains some


myocardium but has a narrow neck.
• Mixed aneurysm is when a true aneurysm develops some
rupture at the edge and forms a pseudoaneurysm with it.
Causes
• Transmural MI
• Trauma or surgery
• Infection such as endocarditis
• Inflammation, autoimmune diseases
• In a literature review of 253 patients with a
pseudoaneurysm in whom the cause was reported, 55
percent were related to MI, particularly of the inferior wall
which was twice as common as anterior infarction.

• Pseudoaneurysms were primarily seen in the inferior or


posterolateral wall after MI (82%), which is consistent with
the greater association with inferior infarction, in the right
ventricular outflow tract after congenital heart surgery, in
the posterior subannular region of the mitral valve after
mitral valve replacement, and in the subaortic region after
aortic valve replacement.

1. Left ventricular pseudoaneurysm. AUFrances C; Romero A; Grady D SOJ , Am Coll Cardiol 1998 Sep;32(3):557-61.
2. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. AUYeo TC; Malouf JF; Oh JK; Seward JB SO .
Ann Intern Med. 1998 Feb 15;128(4):299-305
Predisposing factors
• HTN
• Age above 60
• Females
• Post MI pericarditis
• Use of NSAIDS or steroids
• Late ( more than 7 h) thrombolytic therapy
Common findings
• Presenting symptoms are none to nonspecific but
may include chest pain, dyspnea, syncope,
thromboembolism, arrythmias, hemoptysis.
• Pericardial effusion or re ST elevation post MI
should raise suspicion.
• Unexplained or refractory HF should also raise
suspicion.
• Exam can show the classic to-and-fro murmur
representing flow across the orifice of the
pseudoaneurysm but is not always detectable.
Mechanics
• LV dysfunction develops due to pooling of blood in the sac in
systole causing impaired ejection.
• This leads to ventricular dilatation and subsequent MR.
• ECG and radiographic findings may be nonspecific. 20 %
show ST elevation.
• TEE has an accuracy of 75%
• Cardiac cath is diagnositic (85%) and will be needed as a
preop measure.
X ray findings
LV angio
MRI
• False aneurysms had a ratio of maximal internal width of
the orifice to maximal parallel internal diameter that was
significantly lower than that of true aneurysms (0.73 vs
1.00, P < .001) and had a significantly higher left ventricular
end-diastolic volume (median, 202 vs 136 mL/m(2); P =
.001),
• Marked delayed enhancement of the pericardium is a
characteristic feature of false aneurysm

True versus false left ventricular aneurysm: differentiation with MR imaging--initial


experience. AUKonen E; Merchant N; Gutierrez C; Provost Y; Mickleborough L; Paul NS; Butany
J SO ; Radiology. 2005 Jul;236(1):65-70. Epub 2005 Jun 13.
Complications
• Further rupture and tamponade
( Rates: 30 to 45% and highest in first 3 months)
• Embolism
• HF
Management

• Cath

• Surgery: Endoventricular circular patch plasty with CABG.


Mortality is 7 to 29%

• Urgent repair if found acutely, or elective repair if chronic.

• If chronic, stable, asymptomatic and less than 3 cm then


surgery can be avoided. (Atik et al, Ann Thor Surg 2007)
Bovine pericardial and Dacron sandwich patch
Surgery
• Internal approach, the most preferred one in cases of rent
involving the mitral annulus, posterior wall or large area of
LV involves reopening the left atrium and the correction of
the rent from within.
Outcome
• The reported mortality for such operations is 7%; however,
• Mortality can be as high as 23% to 28% in the acute phase of
myocardial infarction and in redo operations.
Take Home Points
• Untreated pseudoaneurysms have a 30 to 45 percent risk of
rupture and, with medical therapy, a mortality of almost 50
percent.
• Thus, surgery is the preferred therapeutic option. With
current techniques, the perioperative mortality is less than
10 percent; the risk is greater among patients with severe
mitral regurgitation requiring concomitant mitral valve
replacement
Case 2
• A 81-year-old female with past medical history significant
for esophageal stricture with Barrett's esophagus who
presented with increased epigastric abdominal pain,
nausea, hematemesis x2 following an esophageal dilation .
• Workup showed gastric perforation and she underwent
laparotomy
• Post op troponin went upto 0.2
• Echo was done and showed further abnormalities.
Main considerations

• Thrombus
• Tumors
• Endocarditis
Thrombi
• The almost ubiquitous finding of spontaneous echo contrast,
indicative of predisposing stasis, almost always accompanies
thrombus and may be helpful in differentiating thrombi
from tumor or normal anatomy
• Left atrial thrombi are often multiple and vary in size and,
although they attach to the atrial wall, they usually
demonstrate some degree of independent motion
• Small thrombi must be distinguished from the normal
trabeculations
• Older, organized thrombi may show an echogenic series of
layers, representing the lines of Zahn; however, in one
study, the degree of echogenicity did not correlate with the
degree of thrombus organization at pathological
examination
Diagnostic criteria for vegetations 
• With either transthoracic or transesophageal methods, a valvular
vegetation is defined as "a discrete mass of echogenic material
adherent at some point to a leaflet surface and distinct in
character from the remainder of the leaflet" based upon the
following characteristics
• Texture — gray scale and reflectance of myocardium
• Location — upstream side of the valve in the path of the jet or on
prosthetic material
• Characteristic motion — chaotic and orbiting; independent of valve
motion
• Shape — lobulated and amorphous
• Accompanying abnormalities - abscess and pseudoaneurysm,
fistulae, prosthetic dehiscence, paravalvular leak, significant
preexisting or new regurgitation

Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. AUSanfilippo AJ;
Picard MH; Newell JB; Rosas E; Davidoff R; Thomas JD; Weyman AE SOJ Am Coll Cardiol 1991 Nov 1;18(5):1191-
Characteristics of a mass not likely to be
a vegetation include:

• Texture — reflectance of calcium or pericardium (appears


white)
• Location — outflow tract attachment, downstream surface
of valve
• Shape — stringy or hair-like strands with narrow attachment
• Lack of accompanying turbulent flow or regurgitation
Myxoma
• Most common LA tumor
• Commonly from inferior limb of fossa ovale
• Commonly observed symptoms and signs include dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, pulmonary
edema, cough, hemoptysis, edema, and fatigue. Symptoms
may be worse in certain body positions, due to motion of
the tumor within the atrium.
• On physical examination, a characteristic "tumor plop" may
be heard early in diastole
• Can embolise
Echo findings in myxoma
• If the tumor is encapsulated, clear spaces that represent
cysts and highly reflective patches representing bone
formation can be appreciated.
• Careful inspection of an encapsulated tumor also
demonstrates the stalk of attachment at its typical location
along the interatrial septum.
• If the tumor is more amorphous, its attachment is usually
broad based with the mass tapering into a highly mobile tip.
The reflectance or ultrasonic brightness of these masses is
much less vivid.
• myxomas are occasionally biatrial
Others

• Papillary fibroelastomas are the second most common


primary cardiac tumor in adults . Their appearance is often
compared to sea anemones, with frond-like arms emanating
from a stalked central core.
• Angiosarcoma, the most common primary malignant cardiac
tumor