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in the Urgent Setting Edited by: Vladimir Fridman MD Department of Cardiology Long Island College Hospital New York, NY, USA Mario J. Garcia MD Professor, Department of Medicine (Cardiology); Professor, Department of Radiology; Chief, Division of Cardiology; Co-Director, Montefiore Einstein Center for Heart and Vascular Care. New York, NY, USA In the acute care setting, medicine happens at full speed and with little margin for error. As echocardiography plays an ever more important role in the diagnosis of patients who present with symptoms that suggest a cardiovascular emergency, clinicians must learn to collect, process and act on echocardiographic information as quickly and effectively as possible. Practical Manual of Echocardiography in the Urgent Setting covers the essentials of echocardiography in the acute setting, from ultrasound basics to descriptions of all pertinent echocardiographic views to clear, stepwise advice on basic calculations and normal/abnormal ranges. This compact new reference: $ Provides step-by-step guidance to acquiring the correct views and making the necessary calculations to accurately diagnose cardiac conditions commonly encountered in urgent settings. $ Presents information organized by complaint/initial presentation so that readers can work from this first knowledge of the patient through the steps required to pinpoint a diagnosis. $ Covers echo basics, from sound wave characteristics/properties to common device settings to basic ultrasound formulas. $ Includes diagnostic algorithms fitted to address the differential diagnosis in the most commonly- encountered clinical scenarios. RELATED TITLES: Kacharava, et al: Pocket Guide to Echocardiography; ISBN: 978-0-470-67444-4 Sun, et al: Practical Handbook of Echocardiography: 101 Case Studies; ISBN: 978-1-4051-9556-0 Edited by Fridman & Garcia Designed and written by frontline clinicians with extensive experience treating patients, Practical Manual of Echocardiography in the Urgent Setting is the perfect pocket-sized guide for residents in cardiology, emergency medicine, and hospital medicine; trainees in echocardiography; medical students on cardiology or emergency medicine rotations; technicians, nurses, attending physicians—anyone who practices in the urgent setting and who needs reliable guidance on echocardiographic views, data and normal/abnormal ranges to aid rapid diagnosis and decision-making at the point of care. Practical Manual of Echocardiography in the Urgent Setting Practical Manual of Echocardiography Practical Manual of Echocardiography in the Urgent Setting Edited by Vladimir Fridman and Mario J. Garcia Practical Manual of Echocardiography in the Urgent Setting To: – Dr Balendu Vasavada, whose knowledge and dedication to echocardiography has been the basis of this textbook. Many of the images in this book are a direct result of his leadership at the echocardiography ­laboratory of Long Island College Hospital. – Dr Steven Bergmann, who served as a great mentor throughout my training and clinical practice. His tremendous assistance and dedication to cardiology have made my career possible. – Dr Cesare Saponieri, who is responsible for all I know about the p ­ ractice of clinical cardiology. His pursuit of providing great care to patients is truly an inspiration. – Of course, Dr Mario Garcia for spending countless hours going through all the text, figures, and tables in this book. Without him, this book would not be possible. – All of my cardiology colleagues who made this book a reality. Thank you. Practical Manual of Echocardiography in the Urgent Setting Edited by Vladimir Fridman, md Cardiovascular Diseases Brooklyn, NY, USA Mario J. Garcia, md Professor, Department of Medicine (Cardiology) Professor, Department of Radiology Chief, Division of Cardiology Co-Director, Montefiore Einstein Center for Heart and Vascular Care New York, NY, USA A John Wiley & Sons, Ltd., Publication This edition first published 2013, © 2013 by John Wiley & Sons, Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK. Editorial offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA. 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Cover Design: Modern Alchemy LLC Cover image: Mike Austin Set in 9/12 pt Palatino by SPi Publisher Services, Pondicherry, India Printed and bound in Singapore by Ho Printing Singapore Pte ltd 1 2013 Contents Contributors, x Preface, xiv 1 Ultrasound physics, 1 Vladimir Fridman Ultrasound generation, 7 Image formation, 9 Doppler ultrasound, 15 Summary and key points, 22 References, 22 2 The transthoracic examination, 23 Vladimir Fridman and Dennis Finkielstein Performing the echocardiogram, 33 Using the transducer, 35 Steps involved in a comprehensive transthoracic echocardiogram, 37 References, 40 3 Transesophageal echocardiography, 41 Salim Baghdadi and Balendu C. Vasavada Preparation of the patient, 42 Acoustic windows and standard views, 45 Clean-up and maintenance, 54 References, 56 v vi | Contents 4 Ventricles, 57 Deepika Misra and Dayana Eslava Left ventricle, 57 Right ventricle, 66 Atria, 72 Contrast echocardiography, 74 References, 77 5 Left-sided heart valves, 79 Muhammad M. Chaudhry, Ravi Diwan, Yili Huang, and Furqan H. Tejani Aortic valve, 79 Mitral valve, 94 References, 111 6 Right-sided heart valves, 113 Michael J. Levine and Vladimir Fridman Tricuspid valve, 113 Pulmonic valve, 122 Qp/Qs: Pulmonary to systemic flow ratio, 127 References, 127 7 Prosthetic heart valves, 129 Karthik Gujja and Vladimir Fridman Echocardiographic approach to prosthetic heart valves, 132 Approach to suspected valve dysfunction, 134 References, 140 8 The great vessels, 141 Vladimir Fridman and Hejmadi Prabhu Aorta, 141 Pulmonary artery, 147 D-septal shift, 151 References, 152 9 Evaluation of the pericardium, 153 Chirag R. Barbhaiya Pericardial effusions, 153 Cardiac tamponade, 154 Echo-guided pericardiocentesis, 159 Contents | vii Constrictive pericarditis, 161 Differentiation of constrictive pericarditis and restrictive cardiomyopathy, 163 Effusive–constrictive pericarditis, 165 References, 165 10 Specialty echocardiographic examinations, 167 Cesare Saponieri TTE in a VAD patient, 167 Intracardiac echocardiography, 169 TEE in the operating room, 171 Echocardiography to guide percutaneous closure devices placement, 172 References, 173 11 Common artifacts, 174 Padmakshi Singh, Moinakhtar Lala, and Sapan Talati References, 182 12 Hypotension and shock, 183 Sheila Gupta Nadiminti Determination of central venous pressure, stroke volume, cardiac output, and vascular resistance, 183 Hypovolemia, 184 Septic shock, 188 Cardiogenic shock due to left ventricular failure, 189 Cardiogenic shock due to right ventricular failure, 189 Cardiogenic shock due to acute valvular insufficiency or shunt, 190 Acute pulmonary hypertension/pulmonary embolism, 190 References, 193 13 Chest pain syndrome, 195 Sandeep Dhillon and Jagdeep Singh Myocardial Infarction, 195 Aortic dissection, 198 Pulmonary embolus, 199 Other causes, 201 References, 202 viii | Contents 14 C  ardiac causes of syncope and acute neurological events, 204 Erika R. Gehrie Hypovolemia, 205 Arrhythmias, 205 Aortic stenosis, 207 Cardiac tamponade, 207 Pacemaker malfunction, 207 Endocarditis, 207 Pulmonary embolism, 208 Stroke and transient ischemic attacks, 208 Cardiac masses, 212 References, 215 15 Acute dyspnea and heart failure, 216 Mariusz W. Wysoczanski Echocardiogram in “heart failure”, 216 Intracardiac pressures, 217 Echocardiographic approach to dyspnea with hypoxemia, 222 Differential diagnosis for cardiac induced dyspnea, 223 Algorithm for treatment, 223 References, 225 16 Evaluation of a new heart murmur, 226 Vinay Manoranjan Pai Acute valvular regurgitation, 226 Intracardiac shunts, 231 Pericardial effusion, 232 Post myocardial infarction, 232 References, 233 17 Infective endocarditis, 234 Luis Aybar Diagnosis and diagnostic accuracy, 234 Guidelines for use of echocardiography to diagnose endocarditis, 236 Appearance on echocardiography, 236 Complications and risk stratification, 238 Contents | ix Prosthetic valve endocarditis, 239 Cardiac device-related infective endocarditis, 240 References, 241 18 Post-procedural complications, 244 Vladimir Fridman Noncardiac procedures, 244 Cardiac procedures, 245 References, 247 19 “  Quick echo in the emergency department”: What the EM physician needs to know and do, 248 Dimitry Bosoy and Alexander Tsukerman Goal of FOCUS, 248 Clinical use of FOCUS, 250 References, 252 Index, 253