Case Conf Jan 09

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Echo Quiz

Echo Quiz 1

EKG Quiz 2


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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.

Case 1


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

Findings:


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It is a rupture of the myocardial free wall

that is contained by pericardial adhesions.

It has a narrow neck and is devoid ofmyocardium 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.

Pseudoaneurysm


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Transmural MI

Trauma or surgery

Infection such as endocarditis

Inflammation, autoimmune diseases

Causes


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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 withthe 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


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HTN

Age above 60

Females

Post MI pericarditis Use of NSAIDS or steroids

Late ( more than 7 h) thrombolytic therapy

Predisposing factors


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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.

Mechanics


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X ray findings


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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)

Management


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Bovine pericardial and Dacron sandwich patch


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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.

Surgery


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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.


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Thrombi

The almost ubiquitous finding of spontaneous echo contrast,indicative of predisposing stasis, almost always accompaniesthrombus and may be helpful in differentiating thrombifrom tumor or normal anatomy

Left atrial thrombi are often multiple and vary in size and,although they attach to the atrial wall, they usuallydemonstrate some degree of independent motion

Small thrombi must be distinguished from the normaltrabeculations

Older, organized thrombi may show an echogenic series oflayers, representing the lines of Zahn; however, in onestudy, the degree of echogenicity did not correlate with thedegree of thrombus organization at pathologicalexamination


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Diagnostic criteria for vegetations

With either transthoracic or transesophageal methods, a valvularvegetation is defined as "a discrete mass of echogenic materialadherent at some point to a leaflet surface and distinct incharacter from the remainder of the leaflet" based upon thefollowing characteristics

Texture gray scale and reflectance of myocardium

Location upstream side of the valve in the path of the jet or onprosthetic material

Characteristic motion chaotic and orbiting; independent of valvemotion

Shape lobulated and amorphous Accompanying abnormalities - abscess and pseudoaneurysm,fistulae, prosthetic dehiscence, paravalvular leak, significantpreexisting 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-


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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


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Myxoma

Most common LA tumor

Commonly from inferior limb of fossa ovale

Commonly observed symptoms and signs include dyspnea,

orthopnea, paroxysmal nocturnal dyspnea, pulmonaryedema, 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


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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


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Documents

Case Conf Jan 09