Cas du 13/04/2015: Where to measure the ratio?

Presentation: A patient presents with the following echo loop.

#1: Where do you measure the width of the aortic regurgitant jet?
#2: Where and when do you measure the LVOT diameter?
 #3: What is the severity of the aortic regurgitation?
 #4: Should this patient have an AVR if they are asymptomatic? Symptomatic?


























Explanation: The AR jet should be measured as close to the aortic valve annulus as possible. The LVOT diameter should be measured in mid systole when the LVOT is at it's widest.  The AR jet should be measured during diastole when it is it's widest which is the early part of diastole when the gradient is the highest.  That ratio helps determine the severity (ARdiameter/LVOT diameter) of the aortic regurgitation.

If the ratio is less than 25% then trace AR is present. If the ratio is less than 46% then mild AR is present. If the ratio is less than 64% then moderate AR is present. Any ratio > 64% is considered severe AR.

In this patient the jet is not of uniform width.  The jet is very thin and then widens in the LVOT. It appears, without directly measuring the jet and LVOT width's, that the jet is less than 64% but greater than 25% of the LVOT diameter.  Therefore, it appears that the AR is moderate.

While many discussion occur about when to operate on AR, the current recommendations are to only operate when the LV severely dilates, when the LVEF falls, or when symptoms appear. In the asymptomatic pateint with a normal LVEF, an AVR is not indicated until the LVEDD > 70-75 mm or the LVESD > 50-55 mm.  If the LVEF is < 50% or symptoms appear with significant AR apparently the etiology, an AVR is indicated.

Patients with decreased LVEF due to untreated AR have a much high mortality rate.
 

Cas du 11/04/2015: Aortic Valve Calcification

Presentation: A patient presents for a CABG with this echo loop.








#1: What is the diagnosis?

#2: What is the etiology of the aortic valvular disease?

Explanation: The diagnosis is aortic valve stenosis or aortic valve sclerosis. A gradient must be present for aortic valve stenosis to be diagnosed and from this echo loop, it appears that the aortic valve area would be around 1.2 cm2. Sclerosis is present when one or more leaflets are hypomobile but a gradient is not present.

The etiology is calcific aortic sclerosis/stenosis. Calcific involvement starts at the base of the leaflets and moves into the body of the leaflets. Rheumatic disease is a leaflet edge inflammatory disease where fibrosis and calcium deposition occurs and then spreads to the body of the leaflet.

Cas du 09/04/2015: Left Ventricular Shape and Mortality

Presentation: A patient with a long history of hypertension, poorly controlled, presents with this echo loop.

#1: What is the diagnosis?
#2: What is the prognosis of this diagnosis?



















Explanation:

The diagnosis is concentric hypertophy where the left ventricula mass is increased and the left ventricular end-diastolic volume is maintained. In concentric remodeling the left ventricula end diastolic volume (LVEDV) is decreased but the left ventricular mass is maintained. In other words, in concentric hypertophy the heart  "grows out" and in concentric remodeling the heart "grows in".

 

Patients with hypertrophy, concentric hypertrophy or concentric remodeling, have decreased survival compared to normal hearts. Treatment where a concentric remodeled heart  or a concentric hypertrophied heart normalizes improves survival.

Cas du 06/04/2015: Aortic Valve String

Presentation: A patient scheduled for a CABG has the following echo loop.

#1: What is the diagnosis?
#2: What is the recommended therapy?
























Explanation: The diagnosis is Lambl's Excressence (LE). The differential diagnosis would be an artifact, thrombus, redundant AV cusp, aortic dissection intimal flap, and a papillary fibroeslastoma (PFE). Artifacts can be ruled out by being absent in other imaging planes. A thrombus is usually a thick globular structure whereas this is a thin, filamentous, flapping structure. If the cusp edges can be visualized, then redundant cusp tissue is not th e etiology. PFE are usually small, pedunculated, mobile masses. PFE are jelly-like whereas LE are fibrous tissue.

LE can be associated with CVA/TIAs but some studies dispute the association. The recommendation for an asymptomatic patient is to not remove the LE while antithrombotic therapy may be reasonable. For patients who have had a CVA/TIA where LE is the only abnormality - the current recommendation is to not  remove the LE, although some have advocated LE resection in those settings.

Cas du 04/03/2015: A billowing structure in the LA

Presentation: A patient had the following echo loop.

#1: What is the diagnosis?
#2: Is the RAP higher than, equal to, or lower than the LAP?
#3: What is your recommended therapy for the diagnosis?













Explanation:

The diagnosis is a huge interatrial septal aneurysm (IASA). The RAP exceeds the LAP throughout the cardiac cycle because the aneurysm never enters the RA.  There might be equalization of the RAP and the LAP at the end of diastole.

 

IASA is associated with atrial fibrillation, embolic strokes and migraine headaches.  Treatment remain controversial in that asymptomatic patients may not have any complications from their IASA.  Patients with a history of migraine headaches have had their PFO closed by a device with resolution of their headaches, but, it is unclear if those results will translate to closure of an IASA. Certianly, patients with a history of a stroke or TIA where the IASA is the most likely etiology, should have corrective therapy or be on prophylactic therapy.

Cas du 03/04/2015: Acute SOB

Presentation: A patient presented with acute shortness of breath. The following echo loop was obtained.

#1: What is the diagnosis?


#2: What is your recommended therapy?





















Explanation: The diagnosis is an acute pulmonary embolus. The embolus in the right pulmonary artery is adhered to the right pulmonary artery wall. The pulmonary artery does not appear to be significantly dilated. A PAC was even floated into the right pulmonary artery so either both sides are equally obstructed or the obstruction in the right pulmonary artery is not severe.

The recommended therapy is conservative with heparin anticoagulation/TPA. Directly delivered TPA is indicated in compromised patients. Operative intervention or mechanical percutaneous pulmonary embolectomy is indicated in massive pulmonary embolism where the oxygenation and/or cardiovascular status is unstable and/or life-threatening. Acute right ventricular dilation is a poor prognostic sign and does not respond to pulmonary vasodilators.

Echocardiography is useful for initial assessment of the right ventricular function, pulmonary artery pressure, the presence of a shunt, pulmonary regurgitation, tricuspid regurgitation, thrombus location, and global cardiac function. Serial echocardiographic assessments can help determine if the therapy is effective.