Case Conf Jan 09

Echo Quiz Echo Quiz 1 EKG Quiz 2

Case 1 • Mr. TGH is a 46 yr old man with recent Inf. Wall STEMI and S/P PTCA with BMS was admitted back to the hospital in a week with shortness of breath and leg swelling. • • • •

VS: T 98 P 96 BP 110/56 RR 18 with 99% sats

• Physical exam is unremarkable except for pitting leg edema.

• EKG and 2 D Echo was ordered as part of the workup. • Findings:

Pseudoaneurysm • It is a rupture of the myocardial free wall that is contained by pericardial adhesions. • It has a narrow neck and is devoid of myocardium in the walls. • Pseudo-false aneurysm is when the wall contains some myocardium but has a narrow neck. • Mixed aneurysm is when a true aneurysm develops some rupture at the edge and forms a pseudoaneurysm with it.

Causes • • • •

Transmural MI Trauma or surgery Infection such as endocarditis Inflammation, autoimmune diseases

• In a literature review of 253 patients with a pseudoaneurysm in whom the cause was reported, 55 percent were related to MI, particularly of the inferior wall which was twice as common as anterior infarction. • Pseudoaneurysms were primarily seen in the inferior or posterolateral wall after MI (82%), which is consistent with the greater association with inferior infarction, in the right ventricular outflow tract after congenital heart surgery, in the posterior subannular region of the mitral valve after mitral valve replacement, and in the subaortic region after aortic valve replacement.

1. Left ventricular pseudoaneurysm. AUFrances C; Romero A; Grady D SOJ , Am Coll Cardiol 1998 Sep;32(3):557-61. 2. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. AUYeo TC; Malouf JF; Oh JK; Seward JB SO . Ann Intern Med. 1998 Feb 15;128(4):299-305

Predisposing factors • • • • • •

HTN Age above 60 Females Post MI pericarditis Use of NSAIDS or steroids Late ( more than 7 h) thrombolytic therapy

Common findings • Presenting symptoms are none to nonspecific but may include chest pain, dyspnea, syncope, thromboembolism, arrythmias, hemoptysis. • Pericardial effusion or re ST elevation post MI should raise suspicion. • Unexplained or refractory HF should also raise suspicion. • Exam can show the classic to-and-fro murmur representing flow across the orifice of the pseudoaneurysm but is not always detectable.

Mechanics • LV dysfunction develops due to pooling of blood in the sac in systole causing impaired ejection. • This leads to ventricular dilatation and subsequent MR. • ECG and radiographic findings may be nonspecific. 20 % show ST elevation. • TEE has an accuracy of 75% • Cardiac cath is diagnositic (85%) and will be needed as a preop measure.

X ray findings

LV angio

MRI • False aneurysms had a ratio of maximal internal width of the orifice to maximal parallel internal diameter that was significantly lower than that of true aneurysms (0.73 vs 1.00, P < .001) and had a significantly higher left ventricular end-diastolic volume (median, 202 vs 136 mL/m(2); P = .001), • Marked delayed enhancement of the pericardium is a characteristic feature of false aneurysm

True versus false left ventricular aneurysm: differentiation with MR imaging--initial experience. AUKonen E; Merchant N; Gutierrez C; Provost Y; Mickleborough L; Paul NS; Butany J SO ; Radiology. 2005 Jul;236(1):65-70. Epub 2005 Jun 13.

Complications • Further rupture and tamponade ( Rates: 30 to 45% and highest in first 3 months)

• Embolism • HF

Management • Cath • Surgery: Endoventricular circular patch plasty with CABG. Mortality is 7 to 29% • Urgent repair if found acutely, or elective repair if chronic. • If chronic, stable, asymptomatic and less than 3 cm then surgery can be avoided. (Atik et al, Ann Thor Surg 2007)

Bovine pericardial and Dacron sandwich patch

Surgery • Internal approach, the most preferred one in cases of rent involving the mitral annulus, posterior wall or large area of LV involves reopening the left atrium and the correction of the rent from within.

Outcome • The reported mortality for such operations is 7%; however, • Mortality can be as high as 23% to 28% in the acute phase of myocardial infarction and in redo operations.

Take Home Points • Untreated pseudoaneurysms have a 30 to 45 percent risk of rupture and, with medical therapy, a mortality of almost 50 percent. • Thus, surgery is the preferred therapeutic option. With current techniques, the perioperative mortality is less than 10 percent; the risk is greater among patients with severe mitral regurgitation requiring concomitant mitral valve replacement

Case 2 • A 81-year-old female with past medical history significant for esophageal stricture with Barrett's esophagus who presented with increased epigastric abdominal pain, nausea, hematemesis x2 following an esophageal dilation . • Workup showed gastric perforation and she underwent laparotomy • Post op troponin went upto 0.2 • Echo was done and showed further abnormalities.

Main considerations • Thrombus • Tumors • Endocarditis

Thrombi • The almost ubiquitous finding of spontaneous echo contrast, indicative of predisposing stasis, almost always accompanies thrombus and may be helpful in differentiating thrombi from tumor or normal anatomy • Left atrial thrombi are often multiple and vary in size and, although they attach to the atrial wall, they usually demonstrate some degree of independent motion • Small thrombi must be distinguished from the normal trabeculations • Older, organized thrombi may show an echogenic series of layers, representing the lines of Zahn; however, in one study, the degree of echogenicity did not correlate with the degree of thrombus organization at pathological examination

Diagnostic criteria for vegetations  • With either transthoracic or transesophageal methods, a valvular vegetation is defined as "a discrete mass of echogenic material adherent at some point to a leaflet surface and distinct in character from the remainder of the leaflet" based upon the following characteristics • Texture — gray scale and reflectance of myocardium • Location — upstream side of the valve in the path of the jet or on prosthetic material • Characteristic motion — chaotic and orbiting; independent of valve motion • Shape — lobulated and amorphous • Accompanying abnormalities - abscess and pseudoaneurysm, fistulae, prosthetic dehiscence, paravalvular leak, significant preexisting or new regurgitation Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. AUSanfilippo AJ; Picard MH; Newell JB; Rosas E; Davidoff R; Thomas JD; Weyman AE SOJ Am Coll Cardiol 1991 Nov 1;18(5):1191-

Characteristics of a mass not likely to be a vegetation include: • Texture — reflectance of calcium or pericardium (appears white) • Location — outflow tract attachment, downstream surface of valve • Shape — stringy or hair-like strands with narrow attachment • Lack of accompanying turbulent flow or regurgitation

Myxoma • Most common LA tumor • Commonly from inferior limb of fossa ovale • Commonly observed symptoms and signs include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, cough, hemoptysis, edema, and fatigue. Symptoms may be worse in certain body positions, due to motion of the tumor within the atrium. • On physical examination, a characteristic "tumor plop" may be heard early in diastole • Can embolise

Echo findings in myxoma • If the tumor is encapsulated, clear spaces that represent cysts and highly reflective patches representing bone formation can be appreciated. • Careful inspection of an encapsulated tumor also demonstrates the stalk of attachment at its typical location along the interatrial septum. • If the tumor is more amorphous, its attachment is usually broad based with the mass tapering into a highly mobile tip. The reflectance or ultrasonic brightness of these masses is much less vivid. • myxomas are occasionally biatrial

Others • Papillary fibroelastomas are the second most common primary cardiac tumor in adults . Their appearance is often compared to sea anemones, with frond-like arms emanating from a stalked central core. • Angiosarcoma, the most common primary malignant cardiac tumor