Cas du 29/03/2015: A prosthetic mitral valve mass

Presentation: A patient had a MVR (replacement) several years ago and is asymptomatic but had this echo loop.

#1: What is the definition of endocarditis?
#2: What is the diagnosis?
 

Explanation:

The definition of endocarditis requires one of three following requirements being met:

 (Duke Criteria)

1 - Two major criteria are present

2 - One major and three minor criteria are met

3 - Five minor criteria are met

Major Citeria

1. Positive Blood Culture for Infective Endocarditis

2. Evidence of Endocardial Involvement

• oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets,
  or on implanted material in the absence of an alternative anatomic explanation, or
• abscess, or
• new partial dehiscence of prosthetic valve
• new heart murmur

Minor Criteria

1. Predisposition: Predisposing heart condition or intravenous drug use

2. Fever: temperature > 38.0 ° C (100.4 ° F)

3. Vascular Phonomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

4. Immunologic Criteria: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor

5.Microbiological Evidence: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with IE
6. Echocardiographic Findings: consistent with IE but do not meet a major criterion as noted above

The patient does not meet the above criteria so this mass is a thrombus.

 

Cas du 28/03/15: A large clot

Presentation: A patient present to the operating room with this loop.

#1: What is the definition of tamponade?

#2: Does this patient have tamponade?

#3: Is the patient compensating for the left atrial compression?

Explanation:

The definition of cardiac tamponade is the accumulation of fluid/blood/effusion in the pericardial sac that causes decreased filling of the heart.

With the left atrial compression, the left atrium is inhibited from filling so tamponade would be present. However, classically, tamponade, when global, also exhibits collapse of the low pressure areas (atria and right ventricle). In localized tamponade, the affected area is located where the clot or tumor is located. In this patient the left atrium is collapsed. One would expect that the right ventricle and right atrium to be enlarged from decreased filling of the left atrium. They are not enlarged. Also, decreased filling of the left ventricle would exhibit a small ventricular cavity. It is not decreased in size. Therefore, this echo indicates that flow is at least getting through the left atrium to minimally fill the left ventricle.

This clot may be pleural in it's location. A small separation of the left atrial wall and the pericardium can be seen in the video which would indicated that the clot is in the pleural space. While pleural clots causing left atrial compression are rare, it would be consistent with what is seen in the RA, RV, and LV.

Cas du 27/03/2015: A Big Jet

Presentation: A patient came to the OR with this echo loop.

#1: What is the type and severity of the valve lesion in this loop?
#2: What is the etiology of the valve lesion?

Explanation: This loop shows severe aortic regurgitation.  The aortic regurgitant jet is > 65% of the LVOT diameter and has a high turbulent pattern. The etiology of the aortic regurgitant jet is an ascending aortic aneurysm.  As the STJ dilates, the AV leaflets are pulled apart and the AR jet is central in all views. The STJ is effaced so the etiology of the ascending aortic aneurysm is probably a connective tissue disorder such as Marfans or Cystic Medial Necrosis,

Cas du 26/03/2015 : Pericardial Effusion

Presentation: A patient came to the OR with this echo loop.  The loop shows a pericardial effusion.

#1: What is the severity of the pericardial effusion?

#2: Please discuss how pericardial effusions are placed into the small, medium, or large category?

Explanation: This effusion is a small pericardial effusion.  Pericardial effusions are classified as small, medium, or large and are < 100ml, 100-500ml, or > 500ml respectively.  Since we can't easily measure the volume by echocardiography, small pericardial effusions are typically behind the inferolateral wall (posteriorly) of the heart.  As the effusion enlarges, it fills up the lateral and apical areas.  A large effusion is global and surrounds the heart.  Typically, large effusions will be global and the epicardial to pericardial distance will be more than 1 cm.

Cas du 25/03/2015: Acute Hypotension

Presentation: A patient was having a total hip knee performed.  Upon the last stitch being placed, the patient suddenly went hypotensive are required epinephrine to resuscitate the patient.

#1: What is your diagnosis?

#2: What therapy would you suggest for this patient?

Explanation: The patient has a massive pulmonary embolism that is occluding the right pulmonary artery.  The view is the midesophageal ascending aorta view with eh right pulmonary artery roofing the ascending aorta.

Two main therapies exist - thrombolytic therapy or surgical therapy.  Surgical therapy is reserved for patients who have a contraindication to thrombolytic therapy or where thrombolytic/anticoagulation therapy is ineffective.  While thrombolytic therapy is perferred, sometimes the patient's hemodynamic status is not conducive to waiting for thrombolytic therapy.  If the patient is somewhat hemodynamically stable, operative embolectomy has a mortality rate around 11%.  If the patient is hemodynamically unstable with moderate/severe right ventricular dilation/dysfunction, hemodynamic collapse, with resuscitation, the mortality rate was 85%.

This patient was hemodynamically unstable and had severe RV dysfunction and required epinephrine infusion to maintain minimal perfusion.  We referred the patient to surgery for emergency embolectomy because of the TKA operation would have lead to excessive bleeding from the thrombolytics.

Cas du 24/03/2015: Post CABG Hypotension

Presentation: A patient developed hypotension post CABG.  This echo loop was obtained.

#1: What is your diagnosis?

#2: Explain the echocardiographic signs that you would expect with this diagnosis?

Explanation: The patient has a pericardial clot causing tamponade.

Signs of tamponade depend upon the pericardial sac and the type of pericardial fluid.  In an intact pericardium, an acute rise in volume can quickly cause tamponade without much volume.  However, in chronic effusions, tamponade may occur with several liters of fluid in the pericardium where the pericardium has had time to enlarge. In the patient with an intact pericardium, the pressure in the pericardium rises and in transmitted to the lower pressure chambers of the heart - the atria.  The atria become collapsed and the preload to the heart is decreased despite high filling pressure to the atria (CVP). As the pressure increases more the right ventricle is the first ventricle to be affected.  If the pressure exceeds the diastolic right ventricular pressure the RV collapses during diastole (diastolic collapse) and eventually, with more increased pericardial pressure the right ventricle fails to fill during systole and diastole.

Post-op CABG patients do not have an intact pericardium. Fluid or blood must collect around the heart to affect the chambers.  Fluid pressure is transmitter throughout the chest, whereas, clots will push on adjacent structure - their pressure is more localized and directed to nearby structures. If a clot is by the left atrium, the left atrium will be affected first.  If the pressure exerted exceeds the atrial filling pressure, the atria become collapsed.  Similarly, the ventricles  become affected.

In this video the clot is pushing on the right atrium and right ventricle, inhibiting the filling of those chambers.  Since the filling is compromised, the ejection is compromised also.  The left atrium and ventricle are hypovolemic and the video shows a small left ventricular cavity that is foreshortened.  A clot also exists around the apex of the heart.

Cas du 23/03/2015: Title: On the LAM

Presentation: A patient presented with a cough and a new murmur.

#1: What is your diagnosis?
#2: Explain the echocardiographic signs of your diagnosis?
#3: Discuss the clinical presentation of this diagnosis?



















Explanation: The loops show a left atrial myxoma (LAM).  LAM are round or oval masses that may be undulating and appear with a ground glass texture.  LAM are mobile and are attached to the left atrium, sometimes by a stalk.  LAM can occur just about anywere in the atrium and TV/MV leaflets.

The clinical presentation is usually a CVA, TIA, palpitations, shortness of breath, dyspnea, ventricular failure, syncope, or chest pain.  The LAM is usually benign but can be cancerous.  Acute hemorrhage into the LAM has ocurred and cause acute occlusion of the MV. Atrial myxomas can be single or multiple, can occur in multiple locations in a single atrium or in both atria.