Echo Test #5

What is the systematic approach to echo for CHD?

• History and Natural History

• Identify blood flow in and out of the heart and the connections of various segments of the heart

What segments of the heart need to be assessed for CHD eval?

1. Cardiac position and position of visceral organs

2. Blood flow into the heart

3. Blood flow through the heart

4. Blood flow out of the heart

5. Coronary artery anatomy

What is the most common CHD?

Bicuspid AV

Left-to-right shunts

• Very common

• Volume overload, CHF, Pulmonary HTN, endocarditis

• Some require surgical closure when clinically significant

ASD

• Can cause increased pulmonary blood flow, right heart chamber enlargement, exercise intolerance, and Pulmonary HTN

• Ostium secundum is the most common type, which is within the fossa ovalis

Patent Foramen Ovale (PFO)

• Separation between septum primum and septum secundum. Should close after birth, but some dont.

• Can be a site responsible for an embolic event.

Atrial Septal Aneurysm (ASA)

• Redundancy or saccular deformity of the IAS with increased mobility

• Excursion of IAS

  • > 10mm from septal plane

  • >15 mm total excursion

• Associated with PFO

• Risk for embolic events

VSD

• Very common, may be isolated or in conjunction with other defects

• May cause: increased pulmonary blood flow, left heart chamber enlargement, CHF, exercise intolerance, endocarditis and Pulmonary HTN

VSD types

Muscular, perimembranous, inlet, outlet, maligned

Atrioventricular septal defect (AVSD)

• Caused by a defect in AV separation that results in abnormalities of IAS, IVS, and AV valves

• Partial, Immediate, Complete

Patent ductus arteriousus (PDA)

Ductus arteriosus connects the PA and AO during fetal circulation

Failure to spontaneously close results in persistent patency.

Shunts are usually what way?

Left to right because of the normally higher pressure in the left side

What are the signs of potentially significant left-to-right shunting

Diastolic flattening of IVS

Dilated RA, RV and/or PA

Shunting can be right-to-left or bidirectional with significant what?

Pulmonary HTN, impairment of RV compliance

How does TEE provide better images

• The esophagus is an ideal location because of its proximity to the heart.

• Improved resolution and avoidance of artifacts

• Probe is flexible with a phased matrix array at the distal end controlled by proximal knobs and manual movements

Contraindications of TEE

• Esophageal related: tumor, stricture, fistula, or perforation

• Active upper GI bleed

• Perforated bowel or bowel obstruction

• Unstable cervical spine

• Uncooperative pt

Indications of TEE

• Evaluation of cardiac structures when TTE is nondiagnostic or would be inadequate

• Intraoperative guidance

• Transcatheter procedure guidance

• Critically ill patients

Severity assessment for CHD should include what?

• Physiological factors

  • Hypoexmia, pulmonary hypertension, end-organ dysfunction, exercise limitation, associated arrhythmias

Diagnostic applications for TEE

• Valvular disease

• Suspected prosthetic valve dysfunction

• Evaluate LAA for thrombus prior to cardioversion

• Intracardiac masses

• PFOs and ASDs

• Endocarditis

• Aortic disease

Critical care applications for TEE

• CCU or ICU

• ER

Intraoperative indications for TEE

• CABG

• Valve surgery

Cardiologist role during TEE

Inserts the probe into the esophagus and manipulates the probe for desired views

Echo tech role during TEE

Operates US machine and optimizes pictures, performs measurements, etc.

Nurse role during TEE

Monitors pt status and suctions secretions when necessary

What is the cause of most pulmonary artery abnormalities

Congenital

Causes of dilated main PA

Right-sided volume overload, pulmonary htn, idiopathic

What do you need to evaluate for dilated main PA

right heart

What is Takayasu Arteritis

Inflammatory, which may be autoimmune, of large and medium arteries.

Takayasu arteritis involves what

Aorta and its branches, especially renal, carotid, and subclavian but also PA

Takayasu arteritis leads to what?

Stenosis, occlusions, aneurysms, and end-organ ischemia

Takayasu arteritis symptoms

fever, malaise, weight loss, anorexia

PA involvement specific symptoms for Takayasu arteritis

Dyspnea, hemoptysis, leg edema, increased risk of developing pulmonary htn

AAA causes

degenerative, genetic, aortitis, trauma

Persistent left SVC

Diagnosis caused on dilated coronary sinus

May cause abnormal contour of LA and mimic a mass

Aortic dissection presents as what?

acute onset chest pain

Complications of aortic dissection

Tamponade, aortic regurgation, mal perfusion in areas of aortic branch vessels

Echo findings of Aortic dissection

True lumen is often smaller than false lumen

True lumen expands during systole and shrinks during diastole

Classic features of aortic dissection

• Intimal tear

• Abnormal blood flow from lumen into media

• Creation of a false lumen separated from true lumen by a dissection flap

Malignant Hypertension

Systolic >200

Diastolic > 120

Acute extreme HTN results in what

Organ damage to retina, brain, kidneys

Echo findings for HTN

• Concentric LVH

• Wall thickness

• Severe- late-stage impaired LV systolic and diastolic fx

DM Echo findings

• LVH

• LV diastolic dysfunction

• Decreased LVEF

• Impaired RV diastolic and systolic fx

• Aortic stenosis

Echo findings for obesity

• LV Structural changes (increased LV PSV & EDV, LVH)

• LA enlargement

• LVEF normal

• LV diastolic dysfunction common

HTN progression

Atherosclerosis develops, especially renal artery stenosis, CHF, LVH, eventual LV failure, stroke, AAA, retinal hemorrhage

TAVR treats what?

Severe symptomatic AS

MV Balloon valvuloplasty treats what?

Severe rheumatic MS

MV edge-to-edge repair treats what

MR

Transcatheter valve-in-valve implantation treats what?

Failed surgical MV repairs or bio-prosthesis, diseased MV

What symptoms are caused by decreased CO

• Anxiety

• Chest pain

• SOB

• Diaphoresis

• Hypotension

• Cool, clammy skin

• Cyanosis

• Decreased consciousness

Asystole symptoms

Death

Ventricular fibrilation symptoms

Death

Idioventricular rhythm symptoms

Death

Ventricular tachycardia

Loss of consciousness

Which arrhythmias can cause symptoms of low CO?

• Bradycardia

• Atrial flutter

• Atrial fibrillation

• Junctional escape rhythm

• Junctional tachycardia

• Second-degree heart block type 2

• 3rd degree heart bloc

What is Eisenmenger?

Symptoms that arise from a large shunt

Changes the direction of the shunt from right to left, resulting in significant hypoexmia and cyanosis

What develops from Eisenmenger

Pulmonary hypertension

Sonographic appearance of Eisenmenger?

Large VSD

Equal size and thickness of LV and RV

What is the most common form of cyanotic CHD in adults

Tetralogy of Fallot

What are the components of ToF

RVOT obstruction/PS

Malalignment VSD

Large overriding AO (positioned over VSD)

RV hypertrophy

Associated defects with ToF

• ASD

• Additional VSDs

• AVSD

• Right-sided aortic arch

• anomalous origins of coronary arteries

PLAX of ToF

Malaligned VSD

Overriding aorta over VSD

PSAX of ToF

Anteror and superior deviation of infundibular septum

VSD

Subvalvular PS usually with extension into valvular and supravalvular levels

What are the 2 types of TGA

Complete (classic)

Physiologically or congenitally corrected

Complete (Classic) TGA

2nd most common cause of cyanotic CHD

Must be surgically corrected

Physiologically or congenitally corrected TGA

• Acyanotic

• Ventricular inversion

  • RV supplies the systemic circulation

  • LV connected to PA