Role of TTE

Dr.Ayman AbdelazizAssisstant Prof. of Cardiology Mansoura UniversityEchocardiography in Emergency

Clinical indication1- Hemodynamic instability and/or hypoxemia of unclear aetiolog (i) Suspected tamponade (ii) Pulseless electrical activity (PEA) can be the presenting symptom for: Tamponade Massive pulmonary embolism Acute massive internal hemorrhage Tension pneumothorax2- Aortic dissection 3- Acute coronary syndromes4- Acute valvular pathology, Prosthetic valve malfunction5- Infective endocarditis 6- Massive Pulmonary embolism7- Acute embolic event8- Critically ill patients due to non-cardiac illness: cardiac function and left ventricular (LV) filling may be crucial to guide fluid resuscitation:(a) septic shock and (b) diabetic ketoacidosis.

Echo AlgorithmUnstable patient with shock or pulmonary oedema

Quick targeted Echo (minimum views subcostal , Apical)moderate pericardial effusion Compressed RA/RVCollapsed IVC

Severely enlarged akinetic RV Severe hypokinetic LVSmall hyperdynamic heart Collapsed IVCAssume tamponade

Assume pulmonary embolism

Assume acute pump failure MIMyocarditis)

Assume severe hypovolemia Major internal bleedingSepsis

Pericardial Tamponade

EUROECHO CONGRESS - COPENHAGEN -TEACHING COURSE 2010RV and RA collapse Without thesecollapsescardiactamponade isunlikely

DiagnosisEchocardiogram (tamponade is clinical diagnosis)Pericardial effusionEarly diastolic collapse of the right ventricular free wallLate diastolic compression/collapse of the right atriumSwinging of the heart in its sacRespiratory variation of mitral and tricuspid flowDilated IVC (collapse < 50%)

Respiratory variation of the mitral flow

Echo Guided- PericardiocentesisSubcostal approachTraditional approachBlindIncreased risk of injury to liver, heartEcho guidedLeft parasternal preferred for needle entry orLargest area of fluid collection adjacent to the chest wall

Pulmonary Embolism

Echocardiography in PE: to identify RV overload

RV dilatation.Abnormal right ventricular wall motion. (McConnells sign)Systolic flattening of the interventricular septum.Tricuspid valve insufficiencyIncreased pulmonary arterial pressureInferior vena cava congestionDilated pulmonary arteryRight-sided cardiac thrombus.

Hypotension

Abnormal findingsIs the cause of hypotension cardiac in etiology?Is it due to a pericardial effusion?Is is due to pump failure?

Unexplained HypotensionCardiogenic shock Poor LV contractilityHypovolemiaHyperdynamic ventriculesRight ventricular infarct/large pulmonary embolismMarked RV dilitation/hypokinesisTamponadeRV diastolic collapse

22

Cardiogenic shockDilated left ventricle

Hypocontractile walls

23Chf avi

Small hyperdynamic heartE/A < 1Small (< 20mm) IVC with exaggerated collapse with deep inspiration

Hypovolemia

24

Non Traumatic Resuscitation

Direct VisualizationIs there effective myocardial contractility?AsystoleHypokinesisNormalIs there a pericardial effusion?

ECHO in PEAPerform ECHO during quick look and in pulse checksChange management based on positive findingsPericardial tamponadePericardiocentesisHyperdynamic cardiac wall motionVolume resuscitate

ECHO in PEARV dilatationHypoxic?? Likely PEECG IMI with RV infarct?Profound hypokinesisInotropic supportAsystoleFollow ACLS protocols Early data suggesting poor prognosis

ECHO in PEAFalse positive cardiac motionTransthoracic pacemakerPositive pressure ventilation

Penetrating Chest Trauma

Penetrating Cardiac TraumaPhysicians ability to determine whether there is a hemodynamically significant effusion is poorBecks Triad Dependent on patient cardiovascular statusFindings are often lateDeterminants of hemodynamic compromiseSize of the effusionRate of formation

Acute coronary syndromeEcho in the assessment of complications

Complication of AMIHaemodynamic states Globally reduced LV contractility Hypovolumea Right ventricular infarction Ischemic MRMechanical Complications - Papillary muscle rupture - Ventricular septal rupture - Free wall rupture and tamponadeOther - Left ventricular aneurysm - Mural thrombus

Levine, R. A. N Engl J Med 2004;351:1681-1684Ischaemic mitral regurgitationEUROECHO CONGRESSCOPENHAGENTEACHING COURSE 2010

Ischemic Mitral Regurgitation

Aortic dissection

2AorticDissectionIHPU

Echo Algorithm

Role of TEEAdvantages: Ideal Dx test for AASSafeFastBedside exam or in OR w/o transportIdentifies extent and etiology of injury and associated complicationsSensitive (94-100%) and specific (77-100%)Disadvantages:InvasiveSedationTEE blindspot -- trachea between esophagus and upper ascending aorta

True vs. False Lumen

True vs. False Lumen

17TEE. Additional informationI- Entry tear location and size

Prosthetic valve thrombosis

Prosthetic valve thrombosisRisk factorsInadequate oral anticoagulantInterruption of oral anticoagulation (non cardiac surgery, pregnancy)Prosthetic type: Starr Edwards AFLow EF < 35%LA > 5cmSpontanous echo contrastMVR, TVR

Echo

1. To assess hemodynamic severity

TTE and Doppler echo

2. To assess valve motion and clot burden

TEE and/or fluoroscopy

ECHOCARDIOGRAPHIC SIGNS OFOBSTRUCTIVE PVT

Reduced valve mobilityPresence of thrombusAbnormal transprosthetic flowCentral prosthetic regurgitationElevated transprosthetic gradientsReduced prosthetic area

Dehiscence

Thank you