Echo - Test 4

bacterial causes of infective endocarditis

• staphylococci

• streptococci

• enterococci

fungal causes of infective endocarditis

• candida (most common)

• asperigillus

• histoplasma

risk factors for infective endocarditis

• pts who have undergone cardiac surgery

• pts with AV disease, MR, PDA, VSD, coarctation of the aorta, Marfan’s syndrome

• pts with prosthetic valves

• pts receiving IV drug therapy

• IV drug abusers

• pts with staph infections

• pts with atherosclerotic changes

• hemodialysis pts

symptoms of endocarditis

• fever, chills, night sweats

• new or changed murmur

• fatigue, aching joints and muscles

• SOB, persistent cough

• swelling in feet, legs, abdomen

• unexplained weight loss

• frank or microscopic hematuria

• painful spleen

• osler’s nodes

• petechiae

• sepsis

osler’s nodes

red, tender spots on fingers

petechiae

purple or red spots on skin, whites of eyes, inside mouth

sonographic appearance of endocarditis

• valvular vegetation: oscillating mass with independent motion

• valvular regurgitation

• chamber dilation

• paravalvular abscesses

• pericardial effusion

causes of non-infective endocarditis

• trauma (may be due to a catheter passing through the right heart, may injure TV or PV)

• systemic lupus erythematous

• other hypercoagulative states

• mucin-producing metastatic carcinomas

indications for FoCUS (focused cardiac ultrasound)

• chest pain

• hypotension

• dyspnea

• chest trauma

• cardiac arrest

contrast echo brands

• definity

• optison

• lumason

suboptimal image for contrast echo

at least 2 out of 6 myocardial segments of the left ventricle cannot be visualized in the apical views

contraindications for contrast echo

• lumason: allergy to sulfur hemafluoride

• definity: allergy to perflutren

• optison: allergy to perflutren/blood products

contrast echo optimization - mechanical index

• indicator of cavitation

• a low value of < 0.3 will produce nonlinear acoustic signals, so we utilize harmonic imaging

• higher valve: microbubble oscillation causes microbubble destruction (inertial caviation)

contrast echo optimization - focal zone

placement at the mitral valve level allows for optimal visualization of entire left ventricle and minimizes microsphere disruption

pericardium

double-layered, thin sac around the heart

fibrous pericardium

outer layer that is contiguous with the adventitia of the great vessels

serous pericardium

inner portion of the pericardium that is double-layered

• visceral (epicardium) - inner

• parietal - outer

• between these 2 layers lies the pericardial cavity which normally contains a small amount of serous fluid

layers of pericardium

function of the pericardium

• fix cardial position anatomically

• prevent exvcess movement

• reduce friction between heart and surrounding organs

• acts as a barrier to infection, or malignancy from surrounding organs

criteria for pericarditis diagnosis

• pericardial chest pain

• pericardial friction rub (scratchy sound on auscultation)

• EKG features

  • widespread ST elevation

  • diffuse PR depression

  • diffuse T wave inverison

  • normalization

• new or increasing pericardial effusion

pericardial effusion

abnormal accumulation of pericardial fluid

• may be diffuse or loculated

• leads to an increased intrapericardial pressure which can negatively affect heart function

echo evaluation for pericardial disease

• ventricular interdependence (dysfunction of one ventricle secondary to a disorder of the other)

• MV & TV PW inflow respiratory variation

• annulus versus (medial > lateral mitral annular tissue doppler velocities)

• expiratory hepatic venous diastolic flow reversal

cardiac tamponade

hemodynamic compromise (hypotension and/or decreased cardiac output) due to compression of the cardiac chambers by fluid in the pericardial space

acute cardiac tamponade

• rapid accumulation of fluid

• abrupt bleeding

• leads to cardiogenic shock

causes of acute cardiac tamponade

• penetrating chest wounds

• cardiac contusion

• invasive procedures

• myocardial rupture s/p MI

• ruptured proximal aortic dissection

subacute cardiac tamponade

• develops gradually

• stretching of pericardium can allow for large accumulation of fluid (> 1000 mL)

echo findings of tamponade

• pericardial effusion

• chamber collapse

• IVC plethora (dilated and does not collapse)

• hepatic venous flow pattern change

• respiratory variation of TV and MV PW inflow patterns

• swinging heart

pericardial vs pleural effusion

• pericardial = fluid between heart and aorta

• pleural = fluid behind aorta

restrictive cardiomyopathy

a non-compliant LV associated with elevated diastolic pressures; systolic function usually preserved with impaired diastolic function

least common type of CM

restrictive

signs and symptoms of restrictive CM

• peripheral edema

• ascites

• atrial arrhythmia

• bi-atrial enlargement

• MR/TR

• dyspnea

• palpitations

• fatigue

• poor exercise tolerance

• anorexia

2D echo of restrictive CM

• LVH with bright, shiny echogenic appearance

• RV free wall thickening

• apical obliteration

• normal systolic function with impaired diastolic function

• biatrial enlargement

• pericardial effusion often present

doppler echo of restrictive CM

• MR/TR often moderate to severe

• pulmonary HTN often present with elevated RA pressure

• LVOT gradient may be present

• diastolic dysfunction

infiltrative CM

• form of RCM

• hereditary or acquired

• abnormal substances are deposited in the myocardium causing LV stiffening » impedes normal diastolic filling

endomyocardial fibrosis (EMF)

• RCM

• dense scarring of the mural endocardium

• fibrosis predominated at the apieces and moved up toward the inflow tract

Rt side key EMF echo features

• severe RV diastolic dysfunction

• severe TR

• high RA pressure

• systolic reversal in hepatic veins

Lt side key EMF echo features

• increased apical echogenicity

• posterior MV leaflet is often tethered down or plastered to the LV posterior wall

• echogenic papillary muscles

• apical obliteration in advanced cases

• LA enlargement

• prethrombotic smoke or thrombus