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Posts Tagged ‘echocardiography’

An Echo quiz

Posted in Uncategorized, tagged , , , , , , on January 27, 2026|

It is indeed a tough one. A clue : concentrate inside the pericardial space. (36, year old man , asymptomatic)

Know the diagnosis

X ray

Echo confirmation

Source and reference & Courtesy

1.Jain J, Bhasin D, Gupta A, Isser HS, Bansal S. Cardiac Gunshot Injury: A Serendipitous Miss! JACC Case Rep. 2020 Nov 25;3(1):16-19. doi: 10.1016/j.jaccas.2020.06.049. PMID: 34317461; PMCID: PMC8305087.

Comment : Most curious , who stopped it from entering LV ?

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How do you manage “one & a half” mitral stenosis ?

Posted in Uncategorized, tagged , , , , , , , , , , , , , , on November 26, 2024|

Right from the days we entered medical schools, severe mitral stenosis was defined by less than 1 cm² MVO by echocardiography. It has been sacredly followed in most countries where RHD is prevalent. But, as western data (often derived with eastern patients) redefined the cut off for severe MS to 1.5 cm² in recent years ,.Many of us are amused, rather confused.

Severe MS : Why it was made 1.5 cm² ?

I don’t know. Though, we in India, may not fully agree with this re-definition, there could be some good reason behind this. The bottom line is, we should not miss a functionally significant mitral stenosis, strictly adhering to the anatomical 1 cm² cut-off. After all, we all know, with years of experience in echocardiography ,in a funnel-shaped degenerated mitral valve, we can get whatever MVO we desire to report ! Same story for pressure half time, especially with tachycardia and little mitral regurgitation. We also realize the relationship between gradient and MVO is not at all linear.

So, what shall we do, when numbers play juggler game with us ? Let us go to the basics and learn to make a multi-parametric decision process.

Certain tips in assessing MS severity

1.When there is discrepancy in MVO always go with planimetry. If calcium is there MVO can be problematic; one may add a color flow in short axis to define exact flow borders in mid diastole.

2.If Doppler has multi phasic, humps we must take slopes that occur later in diastole for pressure half time. This is because, the initial rapid filling is influenced by early LV suction forces that may underestimate the MS severity.

3.In AF, always hesitate to diagnose moderate MS. Use a long cycle to measure pressure half time.

4.Finally, always have a look at the degree of pulmonary hypertension, LA enlargement, and sub-valvular disease before deciding if it is moderate or severe.

5.In pregnant women this one and a half MS is going to be really, really tricky to make a decision to Intervene. A fair rule of thumb is, If the mother crosses 20-24 weeks, whatever be the MVO , it is generally a good hemodynamic sign . (Except for the transient high risk period of the post natal uterine involution push and enhanced preload.) Having said that, we must realize , we are living in a near foolish and unrealistic era of demanding zero maternal complication even in high risk pregnancy. Many of us are compelled to do a seemingly unnecessary & risky PTMC during pregnancy due to the collective anxiety of cardio-obstetrics-patient team or a potential legal threat .

Other options

Dobutamine stress is an option , but many are hesitant to do.Stress testing that can be as simple as leg raising and bending 30 times while doing echo and check the gradient(?>20 mmHg)

What is new in hemodynamics of MS ?

There is something called low gradient severe MS (as in aortic stenosis). One must be aware of this. This often occurs in atrial fibrillation, where LA struggle to generate sufficient reservoir-stretch triggered flow gradient The other reason being presence of sub-clinical LV dysfunction hiking downstream pressure attenuating the gradient.(El Sabbagh A, Low-Gradient Severe Mitral Stenosis J Am Heart Assoc. 2019)

Final message

Though we are used to 1 cm² MVO cutoff , we can’t hang on to it strictly. Mind you, even a small gain in orifice can give a dramatic improvement in functional life. We have come across instances of splitting a mitral valve from a patient .8 to 1.5 cm² (technically they are still in severe MS), walking home briskly with a thankful smile. Same thing may happen for a patient with apparently moderate MS, right !

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An extract of “Illustrative echocardiography” in Twenty pages.

Posted in Uncategorized, tagged , , , , on December 15, 2023|

Learning resources in the web, has made the traditional methods of learning & teaching almost redundant.

American society of Echocardiography (ASE) has produced this 20 page PDF document, which covers the entire field of echocardiography , in an Illustrative format.

Take a print out, of this and stick in your lab (If you have space) for an Immersive experience. Hope, sharing this document here doesn’t violate any copyright issues.

ASE POSTER MIND MAPDownload

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How to assess diastolic function in patients with atrial fibrillation by Echocardiography ?

Posted in Atrial fibrillation, tagged , , , , , , , on October 23, 2019|

Assessment of LV diastolic function primarily depends on the Doppler flow profile across the mitral valve and also to be noted are the 2D features of LA and LV for associated abnormality like LVH, LAE etc.

Why diastolic dysfunction assessment difficult in AF ?

Since most diastolic doppler mitral inflow parameters involve analysis of atrial contraction A wave, atrial fibrillation makes it difficult to assess diastolic dysfunction. Since we have only early diastolic velocity to assess, the changes confined to this E velocity is of paramount importance. This E velocity again is subjected to cycle length dependent alteration in both its acceleration and deceleration time , making things still more complex.

However, the following features help diagnose diastolic dysfunction in AF

  1. Lack of significant  E velocity variation (<20%)  Inspite of significant RR interval change.(This implies mean LAP is kept high irrespective of cycle length suggesting elevated baseline LAP)
  2. E deceleration time (<140ms) (In long cycle)
  3. Propagation velocity in color M Mode(Vp)  <45cm/sec might help (RR interval dependent, measure in the long cycle)
  4. E/e” in a single beat by dual doppler probe (Ref 1)  > 10 indicate diastolic dysfunction that correlate with PCWP> 15mmhg (Ref 1)
  5. Finally (and curiously ) presence of AF by itself may imply significant LV diastolic dysfunction. It could be due to an increase in atrial strain and afterload of LA (ie pre A-LVEDP) (Of course, It should be in the absence of mitral valve disease)
  6. LA dimension in AF*

*LA dimension is a very good sign of chronic elevation of LAP and diastolic dysfunction in the absence of mitral valve disease. However, AF can dilate the LA making it a less useful parameter. But, it should be noted in AF both RA and LA dilate together.So,  a disproportionate LA>RA (or if RA is normal size ) could still be a marker of baseline LV diastolic dysfunction.

 

Reference

  1. Kusunose K., Yamada H.,  Nishio S., et al.  Clinical utility of single-beat E/e′ obtained by simultaneous recording of flow and tissue Doppler velocities in atrial fibrillation with preserved systolic function. J Am Coll Cardiol Img 2009 2:1147–1156

 

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An unusual clinical encounter : Gastric “Bradycardia” unmasked by Transthoracic Echo !

Posted in Cardiology-Arrhythmias, Cardiology-Echocardiography, Echo library and gallery, echocardiography, Interesting case study, tagged , , , , , , , , , , , on July 8, 2017| Leave a Comment »

 

A 50-year-old man was referred for dizziness, bradycardia and dysphagia .He was very clear in describing his symptoms and  landed up in Gastro- enterology  OPD , from there was referred to my clinic for cardiac work up . His ECG showed a sinus bradycardia HR of 48 /mt.

Screenshot_2017-07-05-19-09-12

Echocardiogram revealed a structurally normal heart as we expected , but was surprised to spot suspicious shadow in para-sternal long axis view , beneath left atrium.

A well demarcated large mass compressing left atrium.  Trans Thoracic Echocardiography  may not be looking at the heart alone ,(Its technically Thoracic Ultrasound though we may refer it as Echocardiogram   )

  • Aortic aneurysm ?
  • Mediastinal teratoma?
  • Bronchial adenoma ?
  • Esophageal mass ?

The Answer is none of the above

As I was wondering what it was, the staff nurse in charge threw a heavy folder with well worked up gastro Investigations.

That moment , diagnosis became obvious , without a need for further scrutiny to my medical acumen.

Note: The barium swallow of the Esophagus reveals the Intimate relationship between the food tube and the heart as it descends vertically downwards posteriorly  . Realise , how the proximity of these two structures could  confuse a physician when symptoms spill over on either way. (I would have expected a lateral view to show the compressive effect of Esophagus on the left atrium the radiologists felt its not important !)

Yes , it is Achalasia of the cardia , dilating the lower end of esophagus with fluid /mass effect  , compressing the posterior surface of Left atrium.He underwent a myomectomy surgery.

Why bradycardia  ?

There is well described esophago-vagal reflex reproducible by stressful swallow or balloon inflation in the lower end of esophagus at D7 level.(Ki Hoon Kang,Korean J Intern Med. 2005 Mar; 20(1): 68–71.)

Achalasia cardia is known to be associated with symptomatic bradycardia, dizziness, and rarely swallow syncope,though this patient didn’t have a classical syncope.The bradycardia is probably due to high vagotonia, (Hugging effect on posterior surface of heart known for rich innervation of vagus.) . Complete reversal  of bradycardia after esophago -gastric surgery is expected.

Implication for cardiologists

There has been instances of patients with esophageal syncope and reflex bradycardia getting permanent pacemaker therapy. I think , clinical or sub clinical esophageal disorders should be included in the work bradycardia before labelling them as intrinsic sinus node dysfunction .(Ref 1,4)

Final message 

The field of Cardiology  is often referred to as a super specialty atleast in India . I disagree with it strongly. Cardiologists are neither super(eme) nor special .We need to be reminded  its afterall a sub-specialty of Internal medicine and each specialist should undergo retro-training in medicine periodically .This patient is a typical example of a gastric problem entering the domain of cardiac Imaging.Strong foundations in symptom analysis and some degree of medical  curiosity will enable an occasional cardiologist to make a correct diagnosis belonging to a remote foreign specialty.

Reference 

1. Palmer ED. The abnormal upper gastrointestinal vagovagal reflexes that affect the heart. Am J Gastroenterol. 1976;66:513–522. [PubMed]

2.Armstrong PW, McMillan DG, Simon JB. Swallow syncope. Can Med Assoc J. 1985;132:1281–1284. [PMC free article] [PubMed]

3.Turan I, Ersoz G, Bor S..Swallow-induced syncope in a patient with achalasia
4.Dysphagia. 2005 Summer;20(3):238-40  4.Basker MR, Cooper DK. Oesophageal syncope. Ann R Coll Surg Engl. 2000;82:249–253.

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Why ECG reported by a technician is a crime . . . while Echo is not ?

Posted in Uncategorized, tagged , , , on July 20, 2013| 1 Comment »

A Cardiologist will never accept  the diagnosis ,  if a technician reports   a  ECG as normal in a  patient with chest  pain   . . .

While , the same cardiologist  gleefully  accepts  an  echocardiogram   done by a technician  and  treats  the patient without  verifying the veracity of the finding !

Why ?

Some where along the cardiology training  , we have been made to believe Interpreting  Echo Images does not require serious medical knowledge . . . but we strongly believe  ECG  cannot be read by technicians however well they are trained .(In-spite of the fact , Echo images are highly dependent on the person who does it , while ECG wave forms are  totally independent of the person who record it ! )

ECG, still has a  prestigious place  in cardiologist’s mind ,  while Echo is often considered  an inferior  Investigation.  Many of us consider ECG interpretation  as a  brainy work while Echo image acquisition and  interpretation is perceived a dumb job* !

Lastly , probably most importantly ,  performing  Echo  is   a time intensive process for the  present day cardiologist  who’s hands are tied with  catheters and  guide-wires  .He has little time for  the meanly echo . .  . hence  ready to compromise on the quality .

* With due respects to all non invasive cardiologists (That includes the author !)

Final  message

I would think it is  fundamentally inappropriate  for technician  to  report Echocardiogram (Of-course they may record it  ) . Unfortunately , for some reason this practice is continued  in many  parts of world .

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When mitral valve gets fatigued . . . AML moves differently !

Posted in cardaic physiology, Cardiology -unresolved questions, Echo library and gallery, echocardiography, tagged , , , , , on January 31, 2013| Leave a Comment »

Anterior  mitral leaflet (AML)  is an  unique structure  in the heart .It is the fastest moving structure inside the heart . It is the first structure visualised by echocardiogram by  Elder and Hertz in early 1950s .

While AML is known for vigorous motion , the PML motion is subdued . By tradition AML shows a  motion which resembles alphabet M .

But AML is not be taken lightly .  It can change it’s  motion  not only  in pathological states but also in health . One such  pattern is trifid   motion of AML . Following is a Echo Image in  a  perfectly  normal Individual .

mitral valve motion trifid m pattern in m mode echocardiography

mitral valve motion in m mode echocardiography trifid

Possible mechanisms underlying Trifid motion of AML

  •    The plane of  M-mode cut  will change the  mitral valve motion .(May  be this is most common ).M-mode at tip of mitral valve may be trifid  ,however a little beyond may record a  bifid-M pattern .
  • Redundant  mitral valve
  • Mid diastolic AML drag
  • Signs of elevated   LVEDP
  • Finally ,  it could be a   sign of  mitral valve  fatigue after excrcise  . Some of these persons   revert back to M pattern after a brief period of  Trifid motion following exercise .

Does trifid AML motion  result in Tri-phasic doppler  flow as well ?

Mitral valve filling is classical E and A .

This usually correspond to M pattern of anatomical  AML motion .

Do the anatomy goes hand in hand with physiology ? Will the mid diastolic  AML  drag result in augmented flow ?

We are looking  at this phenomenon .

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Let us salute this cardiologist from Paraguay !

Posted in echocardiography, Top ten in cardiology, tagged , on September 30, 2012| Leave a Comment »

Learning and sharing of  knowledge is one of essential qualities of  that make the man kind unique.

But not everyone is ready to do that . A cardiologist from Paraguay shows the way .  . .

Probably a model web site for all academicians .It exemplifies ,  how a medical web site is  to be created and presented .This one is for learning echocardiography .

Though the author calls  , it as  basics it has fairly advanced contents , so it should be useful at levels .

With  due  courtesy  to   Dr  Derliz Mereles I am linking his web site  in my blog .

http://www.echobasics.de/tte-en.html

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A great 3-D Echo course from European society of cardiology . . . free of cost !

Posted in Cardiology teaching websites, Cardiology-Land mark studies, valvular heart disease, tagged , , , , , , , on June 3, 2012| Leave a Comment »

Who said  knowledge comes at a cost . Here is a great resource . Everything about 3D echo

A sample of   3D echo  evaluation of  mitral valve anatomy

http://www.escardio.org/communities/EAE/3d-echo-box/3d-echo-atlas/mitral-valve/Pages/normal-mitral-valve.aspx

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The gimmickery called routine echocardiography in pre-operative cardiac risk assesment !

Posted in Uncategorized, tagged , on February 29, 2012| 3 Comments »

Can you  safely rule out  heart disease before  non cardiac surgery without echocardiography  ?

Yes  ,  in most situations  .  Experience suggest  If the clinical examination is normal  ,  ECG and  X ray  do not show any abnormality  , significant heart disease is ruled out 95/ 100 times.

  Please note  : ECG and X-ray can not  R/O  Coronary  artery disease by  any  degree of   specificity  .Echo cardiogram  also  miserably fails to predict future CAD. But  EST / TMT does this very efficiently!

So where does the  echo comes in the   routine  protocol  in the screening of  heart disease*  ?

“No where” to be precise.  It is only a gimmick . But  many   physicians  and anesthetists are obsessed  with  echo estimated LV EF %  They     invariably   ask for pre  operative echo  for   cardiac risk  stratification.

* On the other hand EST has a strong case for inclusion as a routine screening test before surgery.

What about diastolic dysfunction  ?

ECG and X ray will not miss  a manifest myocardial disease  . However concealed diastolic  dysfunction can not be detected  without echo. It is very common to detect early forms of diastolic relaxation abnormalities in echo . Significance of this is not clear especially  if it is grade 1 . In this situation patient’s  functional capacity comes to our rescue.  In a non functional patient any degree of diastolic dysfunction may increase  the   pulmonary capillary  wedge pressure. These patients must be  monitored and fluid administration should be  be judiciously used.

Final  message

Echocardiography   rarely  comes*  in the  routine  scheme of things in the pre -operative   cardiac risk assessment.

Summary

First question to ask   before non cardiac surgery is  about the  symptoms and functional capacity . ( Do you climb 3 floors  ? Walk 6 km /hr . lift 20kg over a flight of stairs , objectively walk 9 mts on treadmill with std Bruce)  If  he is asymptomatic and his functional capacity is good , for all practical purposes he will be fit for  surgery in cardiac point of view .

Next  , we need to look  the ECG and X ray chest . If one of them shows  some evidence for chamber enlargement / q waves etc ,an echocardiography is ordered .

If  you  really suspect CAD  one should  go for EST or doubtamine stress ECHO.

* Cardiologist lack professional freedom in new age medicine  :

In this funny medical world , a cardiologist can not do what he wants to do . I have encountered surgeons and anesthetics refusing to take a patient for surgery without knowing the  ejection fraction ! Once when  I gave a  surgical fitness without taking an echo there was a furore  from the corporate  desk  of  a  big hospital . How can you  make decision without these modern gadgets they seemed  to  ask  !  Future looks lovely for cardiology !

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