Dr Alistair Cormack

ST6 Cardiology
Stirling Royal Infirmary

EMERGENCY ECHOCARDIOGRAPHY
Indications for emergency
echocardiography
 Pulmonary thromboembolsim (PTE) with
haemodynamic/respiratory compromise
 Pericardial effusion with tamponade
 Aortic dissection
 Complications of acute myocardial infarction
 Peri-arrest
Pulmonary thromboembolism

 Presentation
 Chest pain
 Usually pleuritic, occasionally anginal (RV
ischaemia)
 Dyspnoea
 Sudden onset
 Collapse
 Hypotension, tachycardia
 Associated features
 Swollen leg, recent long-distance travel, recent
surgery, malignancy, immobility
Pulmonary thrombolembolism

 Clinically
 Hypotensive
 Tachycardica
 Dyspnoiec
 Hypoxic
 Raised JVP
 Clear chest
 ECG
 Sinus tachycardia most common
 RBBB, AF, S1Q111T111 patterns possible
Pulmonary thrombolembolism

 Clinically
 Hypotensive
 Tachycardica
 Dyspnoiec
 Hypoxic
 Raised JVP
 Clear chest
 ECG
 Sinus tachycardia most common
 RBBB, AF, S1Q111T111 patterns possible
 CXR typically normal
Pulmonary Embolism Management

 Non-massive
 Heparinisation and warfarinisation
 Massive
 Systolic BP <90mmHg/40mmHg drop in 15
minutes
Massive Pulmonary Embolism

 Management
 Thrombolysis
 Embolectomy
 Catheter fragmentation
 All high risk
Massive Pulmonary embolism

 CTPA is diagnostic modality of choice

Massive Pulmonary embolism

 CTPA is diagnostic modality of choice

 Echocardiography if CT unavailable
 No available, convenient CT
 Patient too unstable
 Echo must support clinical diagnosis of PTE
to consider high risk treatment options
Echo features of acute PTE

 Thrombus in transit
 Thrombus visualization by echocardiography

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Copyright restrictions may apply.

Echo features of acute PTE

 Thrombus in transit
 Unusual
 Acute right ventricular overload/strain
 RV dilatation
 Reduced RV systolic function
 McConnell’s (hinge) sign Relative sparing of RV
apex
Echo features of acute PTE

 Thrombus in transit
 Unusual
 Acute right ventricular overload/strain
 RV dilatation
 Reduced RV systolic function
 McConnell’s (hinge) sign Relative sparing of RV
apex
 Abnormal RV outflow (60/60 sign)
 RVOT acceleration time >60ms if PASP <60mmHg
 Initial risk stratification of patients with suspicion of PE

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Copyright restrictions may apply.

 Diagnostic algorithm for high-risk patients with suspicion of PE

Schellong, S. M. et al. ESC Textbook of Cardiovascular Medicine

10.1093/med/9780199566990.003.037

Copyright restrictions may apply.

Pericardial Effusion

 Aetiology
 Pericarditis
 Viral
 Idiopathic
 Inflammatory
 Malignant
 Iatrogenic
 Traumatic
Pericardial Effusion with
Tamponade
 Occurs when increased pericardial pressure
exceeds right atrial (and thus right ventricular
end diastolic pressure)
 Clinically
 Hypotensive
 Raised JVP
 Peripheral oedema
 Clear chest
 Pulsus paradoxus
Pericardial effusion with
tamponade
ECG – small copmlexes

CXR – enlarged cardiac

silhouette
Pulsus paradoxus in pericardial
effusion
 Drop of systolic BP by 10mmHg with normal
inspiration
 Inspiration lowers thoracic BP, improving
venous return
 Increased RV filling impinges on LV
performance
 (also found in severe asthma, RV infarct,
severe PTE etc.)
Echo findings in tamponade

 Pericardial effusion
 May be minimal in ‘surgical’ cases
 Signs of impaired right sided performance
 RA diastolic collapse
 RV diastolic collapse
 Echocardiographical ‘pulsus paradoxus’
 MV inflow velocities drop by 25% with normal
inspiration
Echo in tamponade

 Assess routes of tamponade relief

 Percutaneous approach
 Subxiphisternal most common
 Apically
 Surgical
 Posterior
 Intervening structures e.g. Massive hepatomegaly
Pericardial tamponade

 Management
 Drainage
 Percutaneous
 Surgical
 Percutaneous
 Fluoroscopy guided
 Echo guided
 Injection of agitated saline into Cook’s needle
Aortic dissection

 Intimal flap of aorta

 May involve any part of aorta
 Ascending dissections managed surgically
 Descending dissections managed medically
 Definitive diagnosis usually made by CT
scanning though TOE reported to have
similar sensitivity and specificity
Transthoracic echo in aortic
dissection
 Only 70% sensitive
 Close to 100% sensitive for life threatening
complications
 Aortic incompetence
 Pericardial effusion
 Left ventricular wall motion abnormality if
coronary involvement
Catastrophic complications of
myocardial infarction
 Ventricular free wall rupture
 Ventricular septal defect
 Acute mitral incompetence
 Increasingly rare
 Usually after transmural infarcts not receiving
timely reperfusion therapy
Mitral Regurgitation in
Myocardial Infarction
 Relatively common
 Usually due to wall motion abnormality
involving papillary muscle, typically inferior,
posterior or lateral myocardial infarction
 Infrequently due to LV and subsequently
mitral annular dilatation
 Rarely, though catastrophically due to flail
mitral valve
 Ruptured papillary muscle head
 Ruptured chordae
Flail mitral valve

 Severe mitral regurgitation

 Murmur may be unimpressive
 High left atrial pressure
 Associated with haemodynamic collapse and
pulmonary oedema
 Severe mitral regurgitation
 Hyperdynamic left ventricle
 Regional wall motion abnormality subtending papillary
muscle
 Valve leaflet may prolapse into left atrium
 May see mass ‘flail’ into left atrium
 Typically non-dilated left atrium
Flail mitral valve

 Management
 Intra-aortic balloon pump
 Coronary arteriography
 Emergency surgery – usually mitral valve
replacement and CABG
 High mortality with medical management
Acute ventricular septal
defect
 Following septal myocardial infarction,
usually trans-mural
 Muscular septum
 Loud systolic murmur
 Acute cardiovascular collapse
Acute VSD

 Echocardiography demonstrates left

ventricular to right ventricular colour flow
 Assiciated peri-defect wall motion
abnormality
 Needs repaired even if no haemodynamic
compromise as usually grows
 Open surgery vs device closure
 Attempt to size defect
Cardiac Rupture

 Typically following transmural infarct with no

reperfusion therapy
 Emptying of left ventricular contents into
pericardial sac
 Rapid deterioration and death from cardiac
tamponade
Cardiac rupture

 Pseudoaneurysm
 Pericardial effusion
 Acute angle of neck of communication
 Cf obtuse angle in true aneurysm
 Colour flow from LV to pericardium
 Wall motion abnormality either side of defect
 Management is immediate surgery
www.heart.bmj.com
Periarrest echo

 Cardiac tamponade
 Massive pulmonary embolism
 Severe left ventricular systolic dysfunction