Echo Board Pt. 2

What is bacterial endocarditis?

Infection of epithelial cells that causes vegetation formation on valves

What is the most common cause of bacterial endocarditis?

Streptococcus viridans or staphylococcus aureus

What are the symptoms of bacterial endocarditis?

1. Fever of unknown origin

2. New murmur

3. Positive bacterial cultures

What is the most common valve affected by bacterial endocarditis?

MV

Where are the vegetations located in those with bacterial endocarditis?

• Atrioventricular valves (TV/MV): Atrial side of valve

• Semilunar valves (AV/PV): Ventricular side of valve

What is Lambl excrescence?

Normal protrusion from aortic leaflets that can be mistaken for aortic valve endocarditis

What is the sonographic appearance of bacterial endocarditis?

1. TEE preferred for visualization

2. Thickened leaflets

3. Mobile mass formation on leaflets

4. Pericardial effusion

5. Complications: Valve ring abscess, fistula formation

Identify this image.

Endocarditis

What is myocarditis?

Inflammation of myocardium

What is pericarditis?

Inflammation of outer later of tissues surrounding heart

What is constrictive pericarditis?

Chronic inflammatory process of pericardium that may cause calcification, adhesion, and fibrosis of pericardial layers

What are the symptoms of constrictive pericarditis?

1. Dyspnea

2. Ascites

3. Jugular vein distension

4. Pericardial “knocking” murmur due to restricted diastolic filling

What is the sonographic appearance of constrictive pericarditis?

1. Thickened pericardium with increased reflectivity

2. LAE

3. Paradoxical motion or early diastolic notching of IVS

4. IVS position varies with respiration

5. MV E/A ratio > 1.5

6. Septal E’ > Lateral E’ or annulus reversus

7. MV velocity increases > 25% with EXPIRATION

8. TV velocity increases > 40% with INSPIRATION

9. Deceleration time < 160 ms

10. No MR or TR

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Thickened pericardium and pericardial effusion seen in those with constrictive pericarditis

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IVS position varies with respiration seen in those with constrictive pericarditis

What is pericardial effusion?

Fluid located anterior to descending aorta

What is the sonographic appearance of pericardial effusion?

1. Small < 1 cm fluid

2. Large > 2 cm fluid

What is pleural effusion?

Fluid located posterior to descending aorta

Identify this image.

Pericardial and pleural effusion

What is cardiac tamponade?

Rapid collection of pericardial fluid that causes pressure build up outside of heart and restricted diastolic filling

What are the symptoms of cardiac tamponade?

Beck’s Triad

• IJV distension

• Hypotension

• Muffled heart sounds on auscultation

What is the sonographic appearance of cardiac tamponade?

1. Diastolic right heart collapse

2. MV velocity decreases with inspiration

3. TV velocity increases with inspiration

4. Pulsus alternans or paradoxus

5. Swinging motion of herat in fluid

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Diastolic RV collapse seen in those with cardiac tamponade

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Cardiac tamponade

• MV velocity decreases with inspiration

• TV velocity increases with inspiration

What percentage of cardiac tumor are benign?

80%

What is the most common benign heart tumor in adults?

Myxoma

What is a myxoma?

Mobile mass in LA with “grape cluster” appearance

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Myxoma

What is the most common benign heart tumor in children?

Rhabdomyoma

What is a rhabdomyoma?

Mass in RV

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Rhabdomyoma

What is the most common valvular tumor?

Papillary fibroelastoma

How is a papillary fibroelastoma differentiated from a valvular vegetation?

Papillary fibroelastomas are located on opposite sides of valvular vegetations

• Atrioventricular valves (TV/MV): Ventricular side

• Semilunar valves (AV/PV): Atrial side

What is the most common primary heart malignancy?

Angiosarcoma

What is an angiosarcoma?

Mass located in RA

What is the most common form of heart malignancy?

Metastasis to heart from another organ

What are the sources of metastasis to the heart?

1. Melanoma

2. Lung

3. Kidney

What is a hiatal hernia?

When stomach protrudes into chest cavity and causes cardiac complications such as LA compression

Identify this image.

Hiatal hernia

What is a mechanical valve?

Man-made valve used to replace damaged structures

What are examples of mechanical valves?

1. Ball-Cage such as Starr-Edwards

2. Floating disk

3. Monocuspid tilting disk such as Bjork-Schiley

4. Bicuspid tilting disk such as St Jude

What is a bioprosthetic valve?

Natural and nonviable tissue used to replace damaged structures

Bioprosthetic valves contain…

3 leaflets

What is a homograft or allograft?

Bioprosthetic valve that comes from human donor OTHER than patient themself

What is an autograft?

Bioprosthetic valve or portion of pericardium that comes from patient themself

What is a heterograft?

Bioprosthetic valve that comes from an animal donor

What is the most common heterograft?

AV from pig

What is a transcatheter bioprosthetic valve?

Valve is inserted via catheter through femoral artery and into heart in order to replace open heart surgery

What are the differences between mechanical and bioprosthetic valves?

Mechanical

• Durable and lasts forever

• Requires anticoagulant therapy

• Produces valve masking or shadowing from metallic elements

• Thrombus formation is most common cause of failure

• Increased risk of vegetations or endocarditis

Bioprosthetic

• Lasts up to 10 years

• Does NOT require anticoagulant therapy

• Produces less valve masking or shadowing

• Tissue degeneration or calcification is most common cause of failure

• Vegetations or endocarditis appear similar to native infection

What is the preferred method for evaluating a prosthetic aortic valve?

Velocity ratio or dimensionless index in apical windows

Identify this image.

Paravalvular TAVI/TAVR leak associated with valve failure

What is a transcatheter edge-to-edge repair?

Procedure used to treat MR in patients with EF of 20-50%

Identify this image.

Mitra-clip or transcatheter edge-to-edge repair

What is pannus formation?

Prosthetic valve complication that refers to excessive overgrowth of tissue around valve

What is dehiscence?

Prosthetic valve complication that refers to strut detachment from heart

What is angina?

Chest pain caused by myocardial ischemia

What is stable angina?

Chest pain controlled by medication or rest

What is unstable angina?

Chest pain at rest

What is shortness of breath (SOB)?

Difficulty breathing when at rest

What is dyspnea of exertion (DOE)?

Difficulty breathing with exercise

What is orthopnea?

Difficulty breathing when lying down associated with CHF

What is paroxysmal nocturnal dyspnea?

Difficulty breathing that interrupts sleep associated with pulmonary edema

What is apnea?

Cessation of breathing

What is hemoptysis?

Bloody sputum associated with pulmonary edema, hemorrhage, or MV disease

What is cyanosis?

Blue discoloration of skin associated with pulmonary disease, Eisenmenger syndrome, and Tetralogy of Fallot

What is edema?

Accumulation of fluids associated with heart failure or systemic HTN

What is jugular vein distension?

Increased right side pressure associated with TV disease, constrictive pericarditis, and tamponade

What is pulsus paradoxus?

> 10 mmHg drop in systolic BP with inspiration associated with constrictive pericarditis, tamponade, pulmonary embolism, or COPD

What is syncope?

Fainting associated with hypotension, arrhythmia, MI, or AV disease

What is a fever?

Increase in body temperature associated with endocarditis

What is cachexia?

Malnurtition and wasting caused by chronic heart disease

What lab values indicate the occurrence of an MI?

Elevated levels of

• Troponin

• Creatine kinase-MB

• Lactic dehydrogenase (LDH)

Identify this image.

Normal heart sounds

1. S1 “lub”: Closure of AV valves after atrial contraction

2. S2 “dub”: Closure of semilunar valves after ventricular contraction

Identify this image.

Abnormal heart sounds

1. Normal S1 “lub”: Closure of AV valves after atrial contraction

2. Normal S2 “dub”: Closure of semilunar valves after ventricular contraction

3. Abnormal S3: Ventricular gallop

4. Abnormal S4: Presystolic or atrial gallop during atrial kick

What are the causes of a third heart sound or S3?

1. Normal heart sound in child or adults < 40

2. Indicates rapid ventricular filling due to

   1. Pregnancy

   2. Anemia

   3. CHF

   4. Dilated CM

   5. Severe valvular regurgitation

   6. Left to right shunting

What are the causes of a fourth heart sound or S4?

1. HTN

2. Severe AS

3. Severe PS

4. CAD

5. CM

What is a pericardial rub?

Heart sound due to inflammation associated with acute pericarditis

What is a pericardial knock?

Heart sound heard in early diastole associated with constrictive pericarditis

What is a murmur?

Heart sound caused by turbulence of blood as it crosses a narrow path

What is a functional murmur?

Heart sound caused by rapid flow across normal cardiac valve

What is a pathologic murmur?

Heart sound caused by turbulent flow across diseased cardiac valves or cardiac defects

What is a systolic murmur?

Murmur that occurs during S1 and S2

What are the causes of a SYSTOLIC EJECTION murmur or EJECTION CLICK?

1. Congenital AS (BAV)

2. Congenital PS

3. HOCM

What are the causes of a MID SYSTOLIC murmur?

1. AS or dilation of aortic root

2. PS or dilation of pulmonary trunk

3. Increased flow through normal semilunar vales

What is a midsystolic click?

Heart sound heard in mid to late systole associated with MVP

What are the causes of a LATE SYSTOLIC murmur?

1. MVP

2. TVP

3. Papillary muscle dysfunciton

What are the causes of a HOLOSYSTOLIC murmur?

1. MR

2. TR

3. VSD

What is a diastolic murmur?

Murmur that occurs between S2 of one cardiac cycle and S1 of another

What are the causes of EARLY DIASTOLIC murmurs?

1. AR

2. PR

What are the causes of DIASTOLIC EJECTION murmurs or an OPENING SNAP?

1. MS

2. TS

What are the causes of LATE DIASTOLIC murmurs?

1. Complete heart block

2. Large left to right shunts (PDA, ASD)

What is an Austin Flint murmur?

Functional diastolic murmur caused by severe AR

What is a Dock murmur?

Early diastolic murmur associated with LAD stenosis

What is a continuous murmur?

Murmur caused by continuous flow throughout systole and diastole

What are the causes of a continuous murmur?

1. PDA

2. AVF

3. Anomalous coronary origin

How can the location of a murmur identify the cause?

1. 2nd RIGHT parasternal space: AS

2. 2nd LEFT parasternal space: PS

3. 3rd parasternal space: AR

4. 4th parasternal space: TV disease

5. 5th midclavicular: MV disease

What is the effect of the valsalva maneuver on murmurs?

Increased murmur in those with HOCM and MVP

What is the effect of amyl nitrate on murmurs?

1. Increased murmur in those with LVOT stenosis and MVP

2. Decreased murmur in those with AR or MR

What are the effects of alcohol abuse on the heart?

1. MI

2. Reduced systolic function

3. Dilated CM

What are the effects of diabetes on the heart?

1. CAD

2. LVH

3. Diastolic dysfunction