Feeds:
Posts
Comments

Posts Tagged ‘echocardiography’

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

 

Read Full Post »

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.

Read Full Post »

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 .

Read Full Post »

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 .

Read Full Post »

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

Read Full Post »

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

Read Full Post »

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 !

Read Full Post »

A simple solution from Canada , for all those complex Echocardiography formulas !

Posted in echocardiography, tagged , , , , , , , on January 27, 2011| Leave a Comment »

Few web sites provide   free  cardiology  service.  This one from cardiomath beats  all  ! It makes the job easier for all those cardiologists who spend  lots of time in echo lab . It provides  simple  online tool  for all common calculations in clinical echocardiography

Here is  the link to the website of cardiomath

With  due  Courtesy   to

Author: Dr. Chi-Ming Chow  Developer: Edward Brawer  Illustrator: Ellen Ho
Sponsored by  Canadian society of echocardiography

Read Full Post »

Lesser known achievements in cardiology : PTMC Guided by echocardiography

Posted in Uncategorized, tagged , , , , , , , on September 15, 2010| 1 Comment »

Interventional cardiology has grown leaps and bounds. We are in the era of percutaneous replacement of cardiac valves.  Mitral valvotomy for mitral stenosis is one the stupendous success  stories of interventional cardiology.

In PTMC,  we have a major cardiac valve disease ,  treated without anesthesia  in a  procedure   lasting about 30 minutes and patients  can walk  home within hours of the procedure.

The maximum such procedures are done in developing countries like India, Brazil, and many south Asian , African countries.

It is a procedure requiring continuous  fluroscopy in cath lab. This has been our traditional way of thinking. But now we learn , what we  require is an imaging    modality  for the entry of balloon into IAS and the stenotic  mitral valve .This can be Echo, MRI , CT scan etc not necessarily fluroscopy.

Why not echocardiography to guide the balloon in PTMC ?

This question was  answered successfully . Both TTE and TEE are used .Surprisingly   transthoracic  echo , by itself was   sufficient in many patients to complete  a  PTMC.

The following article in JASE (American society of Echocardiography )  opens new avenues for  echocardiography .The work was done in New Delhi India

http://www.onlinejase.com/article/S0894-7317(05)00073-8/abstract

The most surprising conclusion  from this  study is  , it is suggested complications like cardiac tamponade is less likely in echo guided PTMC !  as we are sure  where we re puncturing  and entering .

Advantages

  • Huge cost advantage.
  • Can be practiced in a wider clinical set up
  • Radiation free (Very important advantage  )
  • Live 3D /Echo and MRI are  expected to improve the  feasibility of this modality .

Caution about TTE/TEE guided PTMC.

  • Not every one can do this procedure.
  • Cardiologists who have mastered catheter based PTMC  can only understand the intricacies of  PTMC
  • While catheters can be easily imaged , when the procedure requires finer guidewire manipulations fluro is a must .
  • Currently this procedure should be done with a cath lab  standby
  • Tackling complications may be an issue , but the most dreaded complication cardiac tamponade is more easily recognised by echocardigraphy
  • Special training on this modality is to be strongly encouraged.Such thing is possible only in country like ours where RHD continues to be rampant.

Final message

Cath guided PTMC is considered  the gold standard .But ,  often  we create gold standards with impure gold ! The IAS puncture and mitral valve crossing is the most blinded  procedure in cath lab.

The same job can be done   better , with good   “ocular orientation”  by simple echocardiography

Often  in medicine , a  simple alternate technique   rarely can  compete with a proven  technique .Thus ,  these  techniques are denied wider  application and hence  fail to  prove  it’s worthiness.

Echo guided pericardial aspiration , MRI guided deep thoracic biopsy  are already established non invasive  assisted intervention , soon we can expect many cardiac intervention will be done in radiation free environment.

Unpopular treatment modalities  need not be synonymous with ineffective  and dangerous  forms of treatment.

Read Full Post »

What is the normal RV size ? How to measure it by echocardiography ?

Posted in Uncategorized, tagged , , , , , , , , , , , , , , on August 12, 2010| Leave a Comment »

It sounds  to be a  simple question . But, cardiology literature is sparse  on the subject.

RV mimics a three dimensional triangular chamber .The inflow, body and outflow align themselves in complex planes .This makes measurement difficult.

What  are the measurements to be made  ?

  • RV inflow tract (RVIT)
  • RV body
  • RV outflow tract (RVOT)
  • RV Free wall thickness

How to measure RV size ?

  • Inflow diameter is assessed in inflow view ( Para sternal long axis,probe  tilted down towards lower  sternal edge (cool . . .That is were tricuspid valve is located !)
  • RV body can be assessed in long axis or 4 chamber view
  • RVOT in short axis view.

What is the normal range ?

RV Body

< 3 cm in parasternal long axis view

<8 cm Long axis ( RV apex to mid point of TV )

RV inflow(RVOT)

<  3- 4cm

RV outflow (RVOT)

1.8 to 3 cm

Note :

  • All measurements are taken in end diastole .
  • The largest diameter of RV is at its inflow(it is roughly equivalent to tricuspid annulus)
  • RVOT size can vary  , generally tapers as it reaches near the pulmonary valve .

How common is the  differential RV enlargement*?

The complex shape and architecture of RV  make  the  direction , sequence  and magnitude of  RV enlargement less predictable .

  • Diastolic loading of RV generally have more uniform enlargement of RV .(Inflow, body, outflow )
  • In dilated cardiomyopathy RV enlargement  common in short axis > long axis
  • Pressure over  loading may not result in uniform enlargement as the pressure points on RV surface is not homogeneous.
  • In congenital heart disease , RV shape and size  depend more on the morphology(location of VSD, infundibular  anatomy, muscle bundles, extent of trabeculations etc)
  • In arrhythmogenic  RV dysplasia (ARVD) outflow  tract enlargement is more dominant.

* The fact that ,  RV can enlarge  in focal and localised manner make it mandatory to measure RV dimension in multiple views and in all possible diameters.

At what  pressure RV begins to enlarge ?

RV is believed to enlarge at > 60mmhg .Hypertrophy is usually precedes dilatation  .

At what volume overload RV begins to enlarge ?

Our experience with ASD indicate when the pulmonary  blood flow  is twice that of systemic blood flow RV is distinctly enlarged. May be it begins to enlarge at>  1.5: 1 shunt

RV begins to enlarge horizontally or longitudinally ?

this aspect is not studied much.  Generally volume overload causes more uniform enlargement.

How does acute RV enlargement differ from chronic RV enlargement ?

Dilatation is more conspicuous in acute RVE ( Pulmonary embolism, RV infarct ) associated wall motion defects and thinning favors acute RVE.

Normal or increased thickness is expected in chronic RV enlargement

Here is a  five-star rated  article on RV dimension

Published in 1986 , still considered a  land mark paper  . . .

Read Full Post »

Older Posts »