Đang tải... (xem toàn văn)
(BQ) Part 2 book Dynamic echocardiography presents the following contents: Coronary artery disease, mechanical complications of myocardial infarction, pericardial disease and intracardiac masses, myocardial diseases, heart failure filling pressures diastology, cardiac resynchr onization therapy, new technology, cases from around the world.
Section VI Coronary Artery Disease VI Chapter 41 Stress Echocardiography in Chest Pain Syndromes Hector R Villarraga, MD, FASE Ischemic heart disease (IHD) remains the leading cause of death in the United States and is the principal contributor to the nation’s morbidity and health care expenditures Cigarette smoking, physical inactivity, obesity, hypertension, and metabolic syndrome also contribute to the high IHD incidence rates among both women and men More than a quarter of a million women die each year in the United States from IHD and its related conditions, and current projections indicate that this number will continue to rise with our aging population.1 The evaluation of IHD in women presents a unique and sometimes difficult challenge for clinicians because of the greater symptom burden and lower prevalence of angiographically significant coronary artery disease (CAD) in women compared with men.1 There are gender differences in the type, frequency, and quality of symptoms of CAD.2 In a patient with a chest pain syndrome, the history, including the presence or absence of conventional risk factors, the physical examination, and the electrocardiogram (ECG) are important factors to consider A noninvasive diagnostic stress test frequently is selected to evaluate for the presence of significant CAD, to discriminate between significant and nonsignificant disease, and to predict prognosis Diagnostics Exercise Electrocardiographic Evaluation The evidence suggests that one should not rely on the exercise ECG alone for diagnostic purposes in the detection of CAD because it is imprecise and has lower accuracy than other diagnostic methods, especially in women Even when exercise stress test risk scores such as the Duke treadmill score are incorporated into the diagnostic method, exercise electrocardiography remains inferior to diagnostic imaging tests, such as exercise echocardiography.3 Exercise Echocardiography Exercise echocardiography combines treadmill or bicycle exercise with ultrasound imaging of the heart with the goal of detecting stress-induced wall motion abnormalities Before exercise, the resting echocardiographic images are obtained from the parasternal and apical windows.4 These standard images include parasternal long-axis, parasternal 188 short-axis, apical four-chamber, apical long-axis, apical twochamber, and apical short-axis views In cases when the parasternal window is suboptimal, the subcostal approach can be used The apical short-axis view proves particularly useful for assessing the presence or absence of apical regional wall motion abnormalities because, in some patients, visualization of the apex can be incomplete or foreshortened in the standard apical views Inferior basal wall motion abnormalities may be difficult to interpret; an abnormality in this region should be documented in two different views, including the basal short-axis view or assessment of the basal inferior septum, which usually has the same coronary vascular supply Once the patient exercises, images are acquired in the same format as during the rest acquisition and ideally are completed within minute after exercise (treadmill) or during peak exercise (bicycle) Acquisition of the postexercise images is challenging because of lung and motion artifacts as well as a limited time window after exercise; however, with the current imaging equipment, the use of harmonics, and occasionally the use of contrast agents, feasibility is excellent.5 The digitized images are displayed side-by-side for comparison with the resting images Continuous tape recording of all stress images is recommended as a backup In our laboratory, this information is also reviewed Analysis of the Exercise Echocardiogram In addition to the global and regional left ventricular response to stress, the adequacy of workload achieved and the presence of symptoms or ECG changes should be considered The additional information obtained from the echocardiogram at rest and immediately after exercise increases the sensitivity and specificity of this diagnostic modality The interpretation of the echocardiographic study should include semiquantitative scoring of each of the segments of the left ventricle at rest and with stress, as previously described.4 The left ventricle is divided into 16 segments (or 17 segments if the apical cap is included) (Fig 41.1) Each segment is analyzed individually and scored on the basis of its motion and systolic thickening as follows: = normal or hypercontractile; = hypokinetic, = akinetic; = dyskinetic, = aneurysmal; or “not seen.” By dividing the sum of the scores by the total number of segments analyzed, a global left ventricular wall motion score index, both at rest and at exercise, can be generated Myocardial ischemia is diagnosed when the postexercise Section VI—Coronary Artery Disease Fig 41.1 The model for semiquantitative segmental evaluation of regional wall motion of the left ventricle is represented The basal inferoseptum and inferior wall and mid-inferior wall are attributed to the right coronary artery, the anteroseptum and anterior wall to the left anterior descending coronary artery, the anterolateral wall to the left anterior descending or circumflex, and the inferolateral wall to the right coronary artery or circumflex The apical cap (seventeenth segment) is attributed to the left anterior descending coronary artery chamber Apical cap Apical Apical lateral septum Mid Mid anterolateral inferoseptum Basal Basal inferoseptum anterolateral chamber Apical cap Apical Apical inferior anterior Mid Mid inferior anterior Basal inferior Basal anterior 189 Long axis Apical cap Apical Apical lateral anterior Mid Mid inferolateral anteroseptum Basal Basal inferolateral anteroseptum Base Mild Anterior Anteroseptum Anterolateral Inferoseptum Inferior Inferolateral Anterior Anteroseptum Inferoseptum Inferior Apex Anterolateral Inferolateral Anterior Septal Lateral Inferior echocardiographic images document a new regional wall motion abnormality or when no hyperdynamic motion develops despite a good exercise work load The cardiologist interpreting the results of the test must analyze the images in a thorough and methodical fashion In addition to assessing the segmental responses to stress, the global left ventricular response to stress also must be considered Normally, the ejection fraction will increase and the left ventricular end systolic volume will decrease in a normal study.4 Types of Exercise Protocols Cycle Ideally the cycle should vary the resistance to the pedaling speed, allowing better power output controls, because it is common for uncooperative or fatigued subjects to decrease their pedaling speed Cycles are calibrated in kilopods or watts Cycle ergonometry is usually less expensive and requires less space than a treadmill (Fig 41.2) Compared with treadmill exercise, upper body motion is usually reduced, making it easier to obtain blood pressure measurements and to record the ECG When subjects with angina perform identical submaximum cycle work in the supine and upright positions, heart rate is higher in the supine position, maximum work performance is lower, and angina develops at a lower double product A major limitation to cycle ergometer testing is the discomfort and fatigue of the quadriceps muscles Normal protocols for exercise testing include initial warm-up (low load) and progressive uninterrupted exercise with increasing loads, an adequate duration in each level, and a recovery period For cycle ergonometry, the initial power output is usually 10 or 25 watts, usually followed by increases of 25 watts every to minutes until end points are reached.6 Treadmill Subjects should not tightly grab the front or side rails because this action decreases the workload and increases the exercise time and muscle artifact Several different treadmill protocols Fig 41.2 Supine bicycle exercise echocardiography is illustrated The patient pedals a cycle ergometer attached to a specially designed bed Echocardiographic imaging is performed at rest and during exercise are in use; the most commonly used is the Bruce protocol The patient of average height may be instructed that the first three stages involve walking and that the fourth stage involves either running or walking It is important to adjust or select the treadmill or cycle ergometer and protocol to the subject being tested The optimal protocol should last between and 12 minutes, and the exercise capacity should be reported in metabolic equivalents (METs) and minutes.6 Accuracy of Exercise Stress Echocardiography in Women Exercise stress echocardiography has reached a state of maturity not only with data regarding its sensitivity and specificity but with outcome and prognosis as well The mean sensitivity of exercise echocardiography in general is 84% with a specificity of 87%; in women the sensitivity ranges from 77% to 88% with a mean weighted specificity of 73%.5 Multiple studies have evaluated outcome and prognosis with respect to cardiac death and cardiovascular events In a 190 Section VI—Coronary Artery Disease study of 5798 consecutive patients7 with known or suspected CAD that included 2476 women with a mean age average of 62 ± 12 years who were monitored for 3.2 ± 1.7 years, the 1-, 3- and 5-year survival rates for women and men with a negative test were 99.8%, 99.2%, and 97.6% and 99.5%, 98%, and 96.7%, respectively For cardiac events, the event-free survival rates for women and men were 99.5%, 97.6%, and 94.9% and 99.5%, 98.0% and 96.7%, respectively, for 1, 3, and years.7 In patients with a normal exercise echo who exercise satisfactorily (more than METs for women and more than METs for men), the cardiac event-free survival rates at 1, 2, and years were 99.2%, 97.8%, and 97.4%, respectively.8 Thus the outcome after a normal exercise echocardiogram is excellent, with an event rate of 2 mm) for identification of multivessel CAD This finding was demonstrated in our case, in which results of the exercise electrocardiogram were positive (which could represent any degree of CAD) but a large number of myocardial segments also were involved in this patient with critical two-vessel disease (Fig 43.2) Regarding the predictive power of SE for localization of the coronary artery involved, Ryan et al.5 studied 309 patients who underwent upright bicycle SE and coronary angiography The overall sensitivity for the diagnosis of CAD was 91%, and the specificity was 78% As expected for any stress technique, the sensitivity for the detection of single-vessel disease was significantly lower than for multivessel disease (86% vs 95%, respectively) Accuracy was higher for lesions in the left anterior descending and right coronary arteries (both 79%) compared with the left circumflex artery (36%, P < 001) Importantly, patients with left circumflex artery disease were correctly identified as ischemic in >90% of cases, but 8 mm/m2) on two-dimensional imaging and an unusual apical origin of the tricuspid regurgitant jet often are the first clues to the diagnosis of Ebstein’s anomaly (Fig 111.2) Paradoxic movement of the basal interventricular septum phasic with right atrial filling and emptying results from atrialization of the inlet portion of the RV Other Imaging Techniques On cardiac catheterization, Ebstein’s anomaly is suspected when a catheter placed in the right atrium records atrial pressures and ventricular electrograms Magnetic resonance imaging is useful for evaluation of RV size and function 464 Section XIV—Congenital Heart Disease Pregnancy References Pregnancy risk is dependent on the severity of Ebstein’s anomaly On one end of the spectrum are women with mild cases of this anomaly who face a low risk On the other end are women with severe cyanosis in whom pregnancy is contraindicated Ebstein W: Concerning a very rare case of insufficiency of the tricuspid valve caused by a congenital malformation [in German] Arch Anat Physiol 238-255, 1866 Hagler DJ: Echocardiographic assessment of Ebstein’s anomaly Prog Pediatr Cardiol 2:28-37, 1993 Attenhofer Jost CH, Connolly HM, et al: Ebstein’s anomaly Circulation 115:277-285, 2007 Marcu CB, Donohue TJ: A young man with palpitations and Ebstein’s anomaly of the tricuspid valve CMAJ 172(12):1553-1554, 2005 4a Hoffman JIE, Kaplan S: The incidence of congenital heart disease J Am Coll Cardiol 39:1890-1900, 2002 Cohen LS, Friedman JM, Jefferson JW, et al: A reevaluation of risk of in utero exposure to lithium JAMA 271:146-150, 1994 Fontana ME, Wooley CF, Goodwin RS, et al: Sail sound in Ebstein’s anomaly of the tricuspid valve Circulation 46:155-164, 1972 Brickner ME, Hillis D, Lange RA: Congenital heart disease: second of two parts N Engl J Med 342:334-342, 2000 Treatment Mild cases of Ebstein’s anomaly can be followed medically Severe cases should be referred to specialized tertiary centers for tricuspid valve reconstructive surgery or tricuspid valve replacement Index A Abscess, aortic root, 169, 170f Adenosine, 222 Afterload mismatch, 18 Alcohol septal ablation, for hypertrophic cardiomyopathy, 294, 298–300, 299f Alfieri stitch, 143 American College of Cardiology/ American Heart Association (ACC/AHA) recommendations for echocardiography in patients with vascular events, 165 for isolated valve replacement in asymptomatic aortic stenosis, 26t for surgery in mitral valve prolapse, 142 for tricuspid valve repair in tricuspid regurgitation, 96 Amyloid heart disease, 258, 260f Amyloidosis, 258 Aneurysm, interatrial septal, 269f Angiotensin-converting enzyme (ACE) inhibitors, in aortic stenosis, 26 Anticoagulation, for pulmonary embolism, 327–328 Aorta artifacts of, 278 atheromatous disease of See Aortic plaque coarctation of See Coarctation of the aorta intramural hematoma of See Intramural hematoma, aortic root measurements of, 8, 8f traumatic disruption of See Traumatic disruption of the aorta (TDA) Aortic dissection See also Intramural hematoma, aortic bicuspid aortic valve and, classification of, 171, 177–178 complications of, 172, 173t Page numbers followed by f indicate figure(s); t, table(s) diagnosis of, 173–174, 173f, 173t, 174f entry and exit sites of, 173f epidemiology of, 171 history of, 171 long-term changes after, 173, 173t pathophysiology of, 171–172, 173t, 177–178 prognosis of, 174, 174t versus traumatic disruption of the aorta, 418t treatment of, 174 type A, 171, 172f type B, 171, 172f Aortic plaque computed tomography of, 180, 181f embolic syndromes associated with, 180 grading of, 167t high-risk, 180–181 magnetic resonance imaging of, 182f stroke risk during invasive procedures and, 181– 182 terminology used to describe, 181t transesophageal echocardiography of, 167, 167f, 180, 181f transthoracic echocardiography of, 180 Aortic prosthetic valve(s) See also Aortic valve replacement bioprosthetic, 108, 124, 125t, 126f complications of, 108–109, 126–127 dysfunction in, 104–106, 105f, 106f echocardiographic assessment of, 109–111, 128f effective orifice area reference values for, 102t high- and low-velocity flows in, 106, 106f mechanical, 108, 124, 125t, 126f obstruction of, 110–111, 110f, 111f pannus in, 109, 127 pressure recovery with, 104–106, 105f prosthesis-patient mismatch with clinical outcomes and, 100–101 demographics of, 100 indexed effective orifice area and, 100, 101f prevention of, 101–103, 102t risk assessment for, 102t pseudoaneurysm in, 122 regurgitation with angiography of, 121, 122t clinical considerations in, 119, 120f Doppler imaging of, 119–121, 120t management of, 122– 123 physiologic versus pathologic, 119 prognosis of, 122–123 transesophageal echocardiography in, 120–121, 120f transthoracic echocardiography in, 119–121, 121f structural degeneration of, 108109 thrombosis in, 109 Aortic regurgitation in Behỗets disease, 410 in bicuspid aortic valve, etiology of, 33 fenfluramine-associated, 335–336, 335f prosthetic See Aortic prosthetic valve(s), regurgitation with quantitation of Doppler techniques combined with echocardiography in, 120t left ventricular measurements for, 34 quantitative methods for, 34, 34f, 35t semiquantitative methods for, 33, 34f, 35t three-dimensional echocardiography in, 35 transesophageal echocardiography in, 35 in subaortic stenosis, 16 Aortic root, measurements of, 8, 8f Aortic stenosis aortic valve calcification in, 24, 24f asymptomatic severe aortic valve replacement for See Aortic valve replacement medical treatment of, 25–26 pressure gradients in, 22, 23f auscultatory features of, 9f in bicuspid aortic valve, clinical progression of, 28 degenerative, echocardiographic evaluation of challenges in, 28, 29f technical issues in, 31, 32f, 32t etiology of, 2, 3f, 3t hemodynamic progression of, 28 with low gradient and poor left ventricular dysfunction diagnosis of, 18–19 dobutamine stress hemodynamics in, 20f transthoracic echocardiography in, 19f, 20f pathophysiology of, 18 treatment of, 19–21, 21t quantitation of severity classifications in, 12–13, 13t transesophageal echocardiography in, 11–12, 12t transthoracic echocardiography in, 11, 12t rheumatic, 4f strain rate measurement in, 391–392 subaortic See Subaortic stenosis Aortic valve bicuspid See Bicuspid aortic valve masses clinical presentation of, 271 465 466 Index Aortic valve (Continued) infective nonneoplastic, 271, 272f, 273 neoplastic, 271 noninfective nonneoplastic, 273, 273f quadricuspid, 2, 4f, 4t, 5t unicuspid, Aortic valve replacement for aortic stenosis with low gradient and left ventricular dysfunction, 19–21, 21t for asymptomatic severe aortic stenosis See also Aortic stenosis ACC/AHA recommendations for, 26t arguments for, 22–23 cardiac neurohormones as outcome predictor for, 25 delay of, 23 echocardiography as outcome predictor for, 23–24, 24f, 25t ESC recommendations for, 26t exercise hemodynamics as outcome predictor for, 25 exercise testing as outcome predictor for, 24–25 surgical considerations in, 23 Apical aneurysm, in Chagas cardiomyopathy, 407, 408f Apical ballooning, left ventricular See Takotsubo cardiomyopathy Apical hypertrophic cardiomyopathy, 301 Arrhythmogenic right ventricular dysplasia (ARVD), 320– 321 Athletes right ventricular structure and function in, 320 sudden cardiac death in arrhythmogenic right ventricular dysplasia and, 320 hypertrophic cardiomyopathy and, 292, 293f Athlete’s heart, 292, 293f Atrial fibrillation ablation for intracardiac echocardiography in, 132 transesophageal echocardiography in, 132, 133f, 134f cardioversion for, 158 conventional, 160–161, 160t, 161t transesophageal echocardiography in patient selection for, 158–160, 159f transesophageal echocardiographyguided, 160–161, 160t, 161t transthoracic echocardiography in patient selection for, 158 characteristics of, 158 diastolic function and left ventricular filling pressure in, 344–345 left atrial appendage closure in, 135, 136–137f thromboembolic events in, 158, 159t Atrial mass(es) See also Cardiac mass(es) benign neoplastic, 266, 267f, 289f benign nonneoplastic, 266, 269f echocardiographic diagnosis of, 280 malignant neoplastic, 267, 269f, 270f natural history of, 267 treatment of, 267 Atrial septal defect (ASD) cardiac catheterization in, 444 chest radiography in, 442 classification of, 440–441, 441f, 441t clinical presentation of, 441–442, 442t electrocardiography of, 442 embryology of, 440 epidemiology of, 438t hemodynamics/ pathophysiology of, 441 incidence of, 439t magnetic resonance imaging of, 444 versus patent foramen ovale, 150, 150f physical examination findings in, 442, 442t prognosis of, 444 transesophageal echocardiography of, 443–444 transthoracic echocardiography of, 442–443, 443f, 444f treatment of, 444 Atrial septal occluder device, 269f Atrioventricular septal defect, 439t B Behỗets disease, cardiovascular involvement in, 410 Bicuspid aortic valve auscultatory features of, 9f with coarctation of the aorta, 460t complications of, 2–3, 5–6, 5t echocardiographic findings in, 6–8, 6f, 6t pathophysiology of, prevalence of, 2, 4t, 439t stenotic, 3f strategy for evaluation of, 9t surveillance of, variations in, 7f Brain natriuretic peptide (BNP), in asymptomatic severe aortic stenosis, 25 C CAD See Coronary artery disease (CAD) Carcinoid heart disease clinical presentation of, 317 pathophysiology of, 317 pulmonic valve involvement in, 318–319, 319f tricuspid valve involvement in, 91, 317–318, 317f, 318f Cardiac amyloidosis, 258, 260f Cardiac catheterization aortic plaque and risk of stroke during, 181–182 in atrial septal defect, 444 in constrictive pericarditis, 255t, 256 in prosthetic aortic regurgitation, 121, 122f in pulmonic stenosis, 331f in restrictive cardiomyopathy, 255t, 260–261 transesophageal echocardiography in, 184 Cardiac mass(es) See also Atrial mass(es) computed tomography of, 283f contrast imaging of limitations of, 282 pathophysiology of, 280 technique for, 281–282, 281f, 282f, 283f, 284f See also Myocardial contrast echocardiography (MCE) echocardiographic diagnosis of, 280 Cardiac resynchronization therapy (CRT) acute versus chronic response to, 356 clinical and echocardiographic response to, 355, 355f ejection fraction and response to, 355–356 mitral regurgitation response to, 357–358, 358f patient selection for, 354, 355f predictors of response to, 354–355, 355f left ventricular dyssynchrony as, 371–373, 372f, 373f See also Left ventricular dyssynchrony mitral regurgitation as, 357 myocardial variability as, 357 reverse remodeling and response to, 355–356 Cardiac sarcoidosis, 260f Cardiac tamponade See Pericardial tamponade Cardiomyopathy Chagas, 407–118, 408f, 408t dilated See Dilated cardiomyopathy (DCM) hypertrophic See Hypertrophic cardiomyopathy (HCM) Takotsubo See Takotsubo cardiomyopathy Cardioversion, for atrial fibrillation, 158 conventional, 160–161, 160t, 161t transesophageal echocardiography in patient selection for, 158–160, 159f transesophageal echocardiography-guided, 160–161, 160t, 161t transthoracic echocardiography in patient selection for, 158 Carpentier system, for mitral valve segment description, 71, 72f CFVR (coronary flow velocity reserve), 426, 427 Chagas cardiomyopathy, 407–118, 408f, 408t Chiari network, 269f, 275–276, 276t Cholesterol crystal embolism, 180 Chronic obstructive pulmonary disease, left ventricular diastolic function evaluation in, 351 Cinefluoroscopy in aortic prosthetic valve obstruction, 111, 111f in mitral prosthetic valve obstruction, 115, 115f Coaptation depth, 84, 85f, 86f Coarctation of the aorta anomalies associated with, 460t Coarctation of the aorta (Continued) bicuspid aortic valve and, 6, 460t chest radiography in, 459 clinical presentation of, 459 definition of, 459 echocardiography of, 459–460, 460f electrocardiography of, 459 epidemiology of, 438t, 459 incidence of, 439t magnetic resonance imaging of, 460, 461f in pregnancy, 460 treatment of, 461 Color flow Doppler imaging in aortic regurgitation, 120t in constrictive pericarditis, 257 in mitral regurgitation, 65–66 in tricuspid regurgitation, 92–93, 93f Color tissue Doppler imaging See Tissue Doppler imaging Common atrium, 441, 441t See also Atrial septal defect (ASD) Computed tomography (CT) in aortic dissection, 173, 173f, 173t in aortic intramural hematoma, 176 in aortic plaque, 180, 181f in atrial lipoma, 289f in cardiac masses, 283f, 286t in congenital absence of pericardium, 262, 263f in constrictive pericarditis, 256, 286t in patent ductus arteriosus, 453, 453f in restrictive cardiomyopathy, 260 in superior pulmonary vein stenosis, 134f Computed tomography coronary angiography (CTA), 219–220 Computed tomography pulmonary angiography (CTPA), 325, 326f Congenital heart disease See also specific defects epidemiology of, 438, 438t incidence of, 439t pulmonic stenosis and, 330 Congenitally corrected transposition of the great arteries anatomic relations in, 455, 456f echocardiography of, 456–457, 457f incidence of, 455 lesions associated with, 455–456 Index Constrictive pericarditis clinical characteristics of, 254, 255t, 256 computed tomography in, 256 demographics of, 254 differential diagnosis of, 254, 255t, 286t echocardiographic findings in, 255t, 256–257, 256f, 257f, 285, 286f, 287f pathophysiology of, 254 versus restrictive cardiomyopathy, 254, 255t treatment of, 257, 285–286 Continuity method for aortic regurgitation quantitation, 34 for mitral valve area calculation, 42–43, 43f Continuous wave Doppler imaging in left ventricular diastolic function evaluation, 351 in left ventricular outflow tract assessment, 296 in prosthetic aortic valve evaluation, 110, 119–121 in prosthetic heart valve evaluation, 125 in prosthetic mitral valve evaluation, 113, 116, 117f in tricuspid regurgitation evaluation, 94, 95f Contrast administration for resting echocardiography, 376–377, 377f for stress echocardiography advantages of, 378 artifacts identification in, 380 indications for, 378 optimization of, 378–379 protocols for, 378 team for, 379 Cor triatriatum, 58 Coronary angiography computed tomographic, 219–220 no-reflow phenomenon on, 232t Coronary artery disease (CAD) computed tomographic coronary angiography in diagnosis of, 219–220 dobutamine stress echocardiography in See Dobutamine stress echocardiography (DSE) echocardiographic imaging of coronary blood flow in clinical implications of, 429 coronary flow velocity reserve, 427, 428f left anterior descending coronary artery, 426 left circumflex coronary artery, 427 posterior descending coronary artery, 426 settings for, 426, 427f technical pitfalls in, 428–429 exercise echocardiography in accuracy of, in men versus women, 189–190 analysis of, 188–189, 189f versus exercise electrocardiography, 188, 190 microbubble contrast during See Myocardial contrast echocardiography (MCE) physiologic principles of, 194, 195f prognostic value of, 216–217, 217f, 218–220, 219f protocols for, 189, 189f sensitivity and specificity of, 194–196 versus SPECT, diagnostic accuracy of, 194–196 views for, 188 with mitral regurgitation, exercise echocardiography in, 75–76 Coronary flow velocity reserve (CFVR), 426, 427 Crista terminalis, 275 CRT See Cardiac resynchronization therapy (CRT) CT See Computed tomography (CT) CTA (computed tomography coronary angiography), 219–220 CTPA (computed tomography pulmonary angiography), 325, 326f Cycle, for exercise echocardiography, 189, 189f See also Exercise echocardiography Cyst(s) echinococcal (hydatid) pericardial, 263–264, 264f pericardial, 262–263, 263f D DCM See Dilated cardiomyopathy (DCM) Deep venous thrombosis (DVT), 324 See also Pulmonary embolism (PE) Diastolic annular velocity, 343f 467 Diastolic function See Left ventricular diastolic function Diastolic stress echocardiography, 213–214, 214f Dilated cardiomyopathy (DCM) causes of, 303f contrast injection for detection of intracardiac thrombus in, 316, 316t echocardiography in, 303–304, 303f, 304f left atrial size in, 312, 314 left ventricle size and function in, 311, 312f three-dimensional echocardiography in, 311–312, 312f, 313f, 314f, 315f d-dimer assay, in pulmonary embolism, 325 Dipyridamole, 222 Dobutamine stress echocardiography (DSE) in aortic stenosis, 19, 21, 21t contrast administration in advantages of, 378 artifact identification in, 380 indications for, 378 optimization of, 379–380 protocols for, 379 team for, 380 with hand-carried ultrasound unit, 396f with myocardial contrast perfusion contrast administration for, 226–227, 227f contrast agents for, 226 diagnostic efficacy and prognostic value of, 229, 229t interpretation of, 228–229, 228f, 229f protocol for, 227–228, 227f set up for, 226 team for, 226 ultrasound system settings for, 227 for myocardial evaluation characteristics of, 203t disadvantages of, 203t versus other modalities, 203t, 204f, 205–206 prognostic value of, 203–204, 204f, 205f protocol for, 201–203 rationale for, 201 responses to, 202–203, 203f with nitroglycerin, 206 for preoperative cardiovascular risk assessment of, 198–199, 199f 468 Index Dobutamine stress echocardiography (DSE) (Continued) prognostic value of, 216–217 protocol for, 198–199 quantitation during, 208, 209f, 209t strain rate measurement in, 391 with three-dimensional echocardiography, 383, 412–413, 413f with tissue Doppler limitations of, 212 positive and negative aspects of, 210t principles of, 208–210, 209f strain rate imaging in, 210–212, 211f, 391 Doppler examination(s) color flow See Color flow Doppler imaging continuous wave See Continuous wave Doppler imaging pulsed wave See Pulsed wave Doppler imaging Dor procedure See Left ventricular infarct exclusion surgery DVT (deep venous thrombosis), 324 See also Pulmonary embolism (PE) Dyspnea, 213–214, 214f E Ebstein’s anomaly characteristics of, 462 chest radiography in, 462–463 clinical presentation of, 462 definition of, 462 echocardiography of, 463, 463f electrocardiography of, 462, 463f epidemiology of, 438t, 462 incidence of, 439t patent foramen ovale in, 463f in pregnancy, 464 treatment of, 464 tricuspid regurgitation in, 91 Echinococcal (hydatid) pericardial cyst, 263–264, 264f Echocardiography exercise See Exercise echocardiography first recording using, 39f hand-carried systems for See Hand-carried ultrasound units (HCUs) myocardial contrast See Myocardial contrast echocardiography (MCE) resting, contrast administration for, 376–377, 377f three-dimensional See Three-dimensional echocardiography transesophageal See Transesophageal echocardiography (TEE) Effective orifice area (EOA) for aortic prosthetic valves, 102t valve prosthesis-patient mismatch and, 100, 101f Effective regurgitant orifice area for mitral regurgitation measurement, 68, 68t for tricuspid regurgitation measurement, 92, 93f Ehlers-Danlos syndrome, aortic dissection in, 171 Eisenmenger syndrome characteristics of, 449 chest radiography in, 450 clinical presentation of, 449–450 echocardiography in, 450 electrocardiography of, 450 epidemiology of, 438t etiology of, 447t treatment of, 450 Electrical alternans, 251f Electrocardiography in coarctation of the aorta, 459 in Ebstein’s anomaly, 462, 463f exercise, in coronary artery disease, 188 in left ventricular free wall rupture, 422, 429, 430f no-reflow phenomenon on, 232t in patent ductus arteriosus, 452 in pericardial tamponade, 251f in pulmonary embolism, 324, 325f in pulmonic stenosis, 331, 331f in restrictive cardiomyopathy, 259 in Takotsubo cardiomyopathy, 306, 307f in ventricular septal defect, 447 Embolism aortic plaque and, 180 in atrial fibrillation, 158, 159t cardiac sources of, 164, 165t aortic atheromatous disease as, 167, 167f, 167t echocardiographic evaluation for ACC/AHA indications for, 165t transthoracic versus transesophageal, 164–167, 165f, 165t left atrium/left atrial appendage as, 164 left ventricle as, 164–165 myxoma as, 166, 166f patent foramen ovale as, 166–167, 167t See also Patent foramen ovale (PFO) valvular lesions as, 165–166 after cardioversion, 160 cholesterol crystal, 180 in left atrial appendage, 158–159, 159f paradoxical, patent foramen ovale and, 149, 154t Endocarditis infective See Infective endocarditis nonbacterial thrombotic, 272f, 273 Endomyocardial biopsy, in hypereosinophilic syndrome, 310, 414 Endomyocardial fibrosis in hypereosinophilic syndrome, 309–310 restrictive cardiomyopathy and, 258 Enoximone stress echocardiography, 206 EOA See Effective orifice area (EOA) European Society of Cardiology (ESC) recommendations, for isolated valve replacement in asymptomatic aortic stenosis, 26t Eustachian valve, 269f, 275 Exercise echocardiography contrast administration in advantages of, 378 artifact identification in, 380 indications for, 378 optimization of, 379–380 protocols for, 379 team for, 380 in coronary artery disease accuracy of, in men versus women, 189–190 analysis of, 188–189, 189f versus exercise electrocardiography, 188, 190 microbubble contrast technology in See Myocardial contrast echocardiography (MCE) physiologic principles of, 194, 195f protocols for, 189, 189f sensitivity and specificity of, 194–196 versus SPECT, diagnostic accuracy of, 194–196 views for, 188 imaging pitfalls in, 191 interpreter pitfalls in, 191 in left ventricular hypertrophy, 191, 192f, 193f limitations of, 191, 192t in mitral stenosis, 46–47, 47f, 52 in nonischemic mitral regurgitation for exclusion of concomitant coronary artery disease, 75–76 for functional capacity assessment, 74 for left ventricular contractile reserve evaluation, 76, 77f peak tricuspid regurgitant velocity after, 75, 75f for pulmonary pressure and right ventricular function evaluation, 75 for valvular function and regurgitation severity assessment, 75 as outcome predictor for aortic valve replacement, 24–25 patient-related pitfalls in, 192–193 prognostic value of, 216 three-dimensional echocardiography in, 383, 412–413, 413f Exercise electrocardiography, in coronary artery disease, 188 Exertional dyspnea, 213–214, 214f F FDG-PET (positron emission tomography), for myocardial evaluation, 203t, 204f, 205–206 Fenfluramine, valve disease associated with, 335–336, 335f, 336f Fibroma, atrial, 266, 267f Flow convergence hemisphere area, in tricuspid regurgitation, 92, 93f Free wall rupture, after myocardial infarction See Left ventricular free wall rupture, after myocardial infarction Functional mitral regurgitation, 84 See also Mitral regurgitation, ischemic H Hand-carried ultrasound units (HCUs) comparisons of, 395, 397t financial considerations for, 397 Hand-carried ultrasound units (HCUs) (Continued) indications for use of, 395, 397f limitations of, 395, 397 technology for, 395, 396f training and qualifications for users of, 397–398 HCM See Hypertrophic cardiomyopathy (HCM) Heart failure cardiac resynchronization therapy for See Cardiac resynchronization therapy (CRT) classification of, 342 diastolic function evaluation in, 342–345, 343f, 344f etiologies of, 342 mitral regurgitation in, 357–358, 358f Heart failure with normal ejection fraction characteristics of, 346 left ventricular mechanics in, 347f, 348–349, 349f Heart murmurs, evaluation of, 8, 8f Hemangioma, atrial, 266, 268f Hemopericardium, 422, 423f Holodiastolic flow reversal, 33, 34f Hydatid (echinococcal) pericardial cyst, 263–264, 264f Hypereosinophilic syndrome (HES) cardiac involvement in, 309–310, 414, 415f, 415t clinical presentation of, 309, 414 demographics of, 414 diagnostic criteria for, 414, 415t pathophysiology of, 415 treatment and prognosis of, 310, 414–415 Hypertrophic cardiomyopathy (HCM) apical, 301 versus athlete’s heart, 292, 293f diagnosis of, 292–293, 292f pathophysiology of, 292 prevalence of, 292 strain rate measurement in, 392, 392f sudden cardiac death in athletes with, 292, 293f treatment of alcohol septal ablation for, 294, 298–300, 299f dual-chamber pacing for, 298 pharmacologic, 293–294 surgical myectomy for, 293–294, 294f, 298 Index I Implantable cardioverter defibrillator (ICD), in hypertrophic cardiomyopathy, 294, 294f Infective endocarditis bicuspid aortic valve and, embolism in, 165–166 epidemiology of, 79 mitral regurgitation in echocardiographic determinants of medical versus surgical therapy for, 79–80 mechanisms of, 79, 80f pathophysiology of, 79 perivalvular abscess in, 169 perivalvular complications of, 169–170, 170f, 170t transthoracic versus transesophageal echocardiography in, 169 Inferior vena cava, tumor infiltration to atria via, 267, 269f Inferior vena cava filter, 328 Inferior vena cava plethora, 250–251, 259f Inlet ventricular septal defect, 448, 449f See also Ventricular septal defect (VSD) Interventricular septum, in primary pulmonary hypertension, 322 Intracardiac mass(es) artifacts masquerading as, 275–278, 276t atrial See Atrial mass(es) imaging modalities for, 286–289, 286t Intramural hematoma, aortic complications of, 176 demographics of, 176 diagnosis of, 176–177, 177f pathophysiology of, 177–178 symptoms of, 176 Intraoperative transesophageal echocardiography See Transesophageal echocardiography, intraoperative Ischemic mitral regurgitation (IMR) See Mitral regurgitation, ischemic Isotonic exercise, 74 See also Exercise echocardiography Isovolumic relaxation time (IVRT), 343 L Lambl’s excrescence, 271, 272f Left anterior descending coronary artery, echocardiographic imaging of, 426 Left atrial appendage closure in atrial fibrillation, 135, 136–137f morphology of, 137f pectinate muscles in, 268f as source of thrombus, 164 thrombus in, 268f, 288f tissue ridge in, 277 transesophageal echocardiography of, 137f, 158–160, 159f, 160f Left atrial function, myocardial imaging for, 386–387 Left atrial size, volume-based measurement of, 342 Left circumflex coronary artery, echocardiographic imaging of, 427 Left ventricle normal function of, 346, 347f systolic function See Left ventricular systolic function three-dimensional echocardiography of, 381–382, 383f torsion mechanics, 394 trabeculations of, 376 wall thickness of, 377, 377f Left ventricular contractile reserve, in nonischemic mitral regurgitation, 76, 77f Left ventricular diastolic function evaluation of in atrial fibrillation, 344–345 left atrial size measurement in, 342 left ventricular filling pressure in, 342 mitral inflow velocity in, 342–343, 343f, 344f, 345, 350, 351f pulmonary vein flow profile in, 343–344, 350, 351f right side of the heart variables in, 351–352 tissue Doppler imaging for, 351, 352f, 392, 392f natural history of, 344f Left ventricular dyssynchrony, 371–372 evaluation of color tissue Doppler imaging in, 362–363, 363f, 364f, 365f, 371–372, 373f interventricular mechanical delay measurement in, 359–360, 361f, 365, 369f, 370f intraventricular mechanical delay measurement in, 359, 360f 469 parasternal views for, 359–360, 360f, 361f as predictor of nonresponse to cardiac resynchronization therapy, 371 pulsed wave tissue Doppler in, 360–362, 361f, 362f three-dimensional echocardiography in, 365, 367f, 368f, 384–385, 384f tissue synchronization imaging in, 363, 366f, 372, 373f two-dimensional echocardiography in, 359, 360f, 364, 371, 373f Left ventricular filling pressure evaluation of, 342, 343f, 344–345 left atrial volume and, 342, 344 natural history of, 344f pulmonary vein flow profile and, 343–344 Left ventricular free wall rupture, after myocardial infarction biochemical markers of, 422 cardiac tamponade in, 423 clinical presentation of, 247, 429 demographics of, 421, 429 diagnosis of, 422–423, 429–430, 430f, 431f medical therapy of, 423, 431 mitral regurgitation in, 422, 423f morphologic patterns of, 429, 430t pathophysiology of, 423–424 risk factors for, 421 surgical treatment of, 423, 431, 432f time of occurrence of, 421–422 Left ventricular hypertrophy, exercise echocardiography in, 191, 192f, 193f Left ventricular infarct exclusion surgery complications of, 147 indications for, 145, 146f intraoperative echocardiography in, 146, 147f outcomes of, 146–147 preoperative echocardiography in, 145–146 procedure for, 145, 146f Left ventricular noncompaction (LVNC) clinical presentation of, 402–403 470 Index Left ventricular noncompaction (LVNC) (Continued) criteria for, 402t echocardiographic findings in, 401, 401f, 402t embryology of, 400 epidemiology and demographics of, 400 genetics of, 400 pathology and histology of, 400 Left ventricular outflow tract (LVOT) echocardiographic evaluation of, 296–297 measurement of, 31, 32f, 32t stroke volume and, 31, 32t Left ventricular stroke volume, by Doppler echocardiography, 303, 304f Left ventricular systolic function in chronic mitral regurgitation, 81, 82f evaluation of, 346, 347f in heart failure with normal ejection fraction, 348 intracavitary flow patterns and, 348–349, 348f normal activation of, 346, 347f Libman-Sacks endocarditis, 272f Lipoma, atrial, 289f Lipomatous hypertrophy of atrial septum, 269f, 276–277, 276t M Magnetic resonance imaging (MRI) in aortic dissection, 173, 173t, 174f in aortic intramural hematoma, 177 in aortic plaque, 182f in atrial septal defect, 444 in cardiac amyloidosis, 260f in cardiac masses, 286t in cardiac sarcoidosis, 260f in coarctation of the aorta, 460, 461f in constrictive pericarditis, 286t, 287f contrast-enhanced, 232, 232t in echinococcal pericardial cysts, 264f in left ventricular free wall rupture, 431, 431f in left ventricular outflow tract assessment, 296–297 in left ventricular thrombus, 288f for left ventricular torsion mechanics assessment, 394 for myocardial evaluation, 203t in restrictive cardiomyopathy, 260, 260f Marfan syndrome, aortic dissection in, 171 McConnell’s sign, 325–327, 325f MCE See Myocardial contrast echocardiography (MCE) Microbubble contrast technology See Myocardial contrast echocardiography (MCE) Mitral annulus, calcification of, 57, 273f, 277–278, 277t Mitral annulus velocity, 342, 343f, 345, 386, 387f Mitral deceleration time, 41, 42, 42f Mitral inflow velocity, 342–343, 344f, 350, 351f Mitral prosthetic valve(s) See also Mitral valve repair/ replacement bioprosthetic, 112 echocardiographic assessment of Doppler, 113–114 transesophageal, 125, 128f, 129f two-dimensional, 113, 125, 127f, 129f mechanical, 112 nonstructural dysfunction of, 113 obstruction of cinefluoroscopy in, 115 Doppler assessment in, 114, 115f transesophageal echocardiography of, 114, 115f transthoracic echocardiography of, 114, 114f pannus in, 113, 113f paravalvular leaks in clinical presentation of, 433 diagnosis of, 433–434, 434f etiology of, 433 percutaneous treatment of, 435–436, 435f surgical treatment of, 434–435 structural degeneration of, 112 thrombosis of, 112–113, 113f Mitral regurgitant volume and fraction, 66–67, 68t Mitral regurgitation classification of, 142 fenfluramine-associated, 335–336, 335f, 336f in infective endocarditis, 79–80, 80f ischemic in anterior versus inferior myocardial infarction, 86 cardiac resynchronization therapy response in, 357–358, 358f clinical situations associated with, 84 echocardiographic features of, 84–85, 85f, 85t, 86f intraoperative transesophageal echocardiography in, 139–141, 140f management of, 86–87 mechanisms of, 84–85, 85f, 85t, 139 pathophysiology of, 84 prognosis of, 85, 86f three-dimensional echocardiography in, 384 in left ventricular free wall rupture, 422, 423f with left ventricular infarct, 146 after myocardial infarction, 248, 248t nonischemic diagnosis of, 62–63, 63f etiology of, 62 exercise echocardiography in for exclusion of concomitant coronary artery disease, 75–76 for functional capacity assessment, 74 for left ventricular contractile reserve evaluation, 76, 77f peak tricuspid regurgitant velocity after, 75, 75f for pulmonary pressure and right ventricular function evaluation, 75 for valvular function and regurgitation severity assessment, 75 with left ventricular dysfunction assessment of, 81, 82f mitral valve surgery in, 81–83, 81f myocardial evaluation in, 76 pathophysiology of, 62 quantification of color Doppler echocardiography of regurgitant jet in the left atrium in, 65–66 color Doppler echocardiography of vena contracta in, 66 Doppler echocardiography in, 65 effective regurgitant orifice area calculation for, 68, 68t mitral regurgitant volume and fracture calculation for, 66–67, 68t proximal flow acceleration zone measurement for, 66 proximal isovelocity surface area calculation for, 67–68, 67f two-dimensional echocardiography in, 65 valve replacement/repair for echocardiographic assessment after, 72–73 echocardiographic guidance during, 71–72 indicators for, 68–69, 69t outcome predictors for, 69t preoperative examination for, 71, 72f three-dimensional echocardiography during, 73, 73f after percutaneous mitral balloon valvulotomy, 53–54, 54t prosthetic transesophageal echocardiography of, 116–118, 117f, 433–434, 434f transthoracic echocardiography of, 116, 117f treatment of, 434–436, 435f Mitral stenosis definition of, 48 epidemiology of, 38 etiology of, 38, 48, 57–58, 58t evaluation of auscultatory findings in, 39 chest radiography for, 40, 40f Doppler echocardiography in, 40 electrocardiography in, 40, 40f exercise echocardiography in, 46–47, 47f, 52 mitral valve area measurement for See Mitral valve area Mitral stenosis (Continued) mitral valve scoring in, 41t, 53t M-mode echocardiography in, 40 phonocardiography in, 39, 40f physical examination in, 39 pressure gradients in, 49–50, 49f real-time three-dimensional echocardiography in, 55, 55f, 384 right atrial pressures in, 44t right heart hemodynamics in, 43–44 three-dimensional echocardiography in, 43, 43f transesophageal echocardiography in, 45, 54–55 two-dimensional echocardiography in, 40 grading of, 44t, 49, 49t historical background of, 38, 39f left atrial enlargement and thrombosis in, 52, 53f mitral regurgitation in, 52–53 after mitral valve repair/ replacement, 141 mitral valve repair/replacement for, 142–143, 143f natural history of, 49 nonlinear deceleration in, 59–60f nonrheumatic forms of, 57–58, 58t pathophysiology of, 38–39, 39f, 48–49 pulmonary hypertension in, 54, 54f rheumatic, 57, 58t rheumatic involvement of other valves in, 53 treatment of, 44t, 45 Mitral supravalvular stenosing ring, 58 Mitral valve area, 38 in atrial fibrillation, 59–60, 60f calculation of, 41, 41t continuity equation for, 42–43, 43f, 51 mitral deceleration time for, 41–42, 42f planimetry for, 50, 50f pressure half-time for, 41–42, 42f, 50–51, 50f, 51f, 59–60f, 59t proximal isovelocity surface area for, 42–43, 43f, 51–52, 52f changes with exercise, 46–47 Index Mitral valve prolapse epidemiology of, 142 mitral valve repair/replacement for indications for, 142 intraoperative/postoperative echocardiography, 143–144 surgical techniques, 143 Mitral valve repair/replacement See also Mitral prosthetic valve(s) complications of, 126–127, 129f for ischemic mitral regurgitation indications for, 86–87 intraoperative transesophageal echocardiography during, 139–140, 140f outcomes of, 87 mitral regurgitation following, 116–118, 117f, 141 mitral stenosis after, 141 for mitral valve prolapse intraoperative/postoperative echocardiography, 143–144 preoperative assessment for, 142–143 surgical techniques, 143 for nonischemic mitral regurgitation indications for, 68–69, 69t with left ventricular dysfunction, 81–83, 82f outcome predictors for, 69t preoperative echocardiographic assessment for, 71, 72f tricuspid regurgitation after, 96 Mitral valve score, 53t MRI See Magnetic resonance imaging (MRI) Murmurs, evaluation of, 8, 8f Muscular ventricular septal defect, 447–448, 448f Myectomy, for hypertrophic cardiomyopathy, 294, 294f Myocardial biopsy, in restrictive cardiomyopathy, 261 Myocardial contrast echocardiography (MCE) acoustic power in, 235, 235f in alcohol septal ablation, 298–299, 299f, 300f in cardiac mass diagnosis limitations of, 282 pathophysiology of, 280 technique for, 281–282, 281f, 282f, 283f, 284f for chest pain assessment in the emergency department, 239–240 contrast agent administration for, 233, 235f, 235t in dobutamine stress echocardiography in acute ischemia, 223–224, 224f contrast administration for, 222–223, 226–227, 227f contrast agents for, 226 diagnostic efficacy and prognostic value of, 207, 223–224, 223f, 229, 229t flash-echo technique in, 223 interpretation of, 228–229, 228f, 229f protocol for, 227–228, 227f set up for, 226 stress perfusion agents for, 222 team for, 226 ultrasound system settings for, 227 for endocardial definition in stress echocardiography, 194, 195f, 196 methods for high mechanical index, 236–237, 236f, 236t, 237t low mechanical index, 235–236, 236f, 237t power-inversion, 237, 237f pulse-inversion, 237, 237f selection of, 237–238, 237t microbubble response in, 233, 239 after myocardial infarction for collateral flow evaluation, 241 contrast perfusion patterns in, 231, 232f, 232t for infarct size evaluation, 240, 241, 241f for prediction of recovery of function, 207 protocols of, 231, 232f for reperfusion assessment, 241 for risk area detection, 240–241 signal generation in, 233, 234f in Takotsubo cardiomyopathy, 307f Myocardial evaluation contrast echocardiography for See Myocardial contrast echocardiography (MCE) dobutamine stress echocardiography for characteristics of, 203t disadvantages of, 203t versus other modalities, 203t, 204f, 205–206 471 prognostic value of, 203–204, 204f, 205f protocol for, 201–203 rationale for, 201 responses to, 202–203, 203f tissue Doppler imaging in, 391 enoximone stress echocardiography for, 206 imaging techniques for, 201, 203t of left ventricular torsion mechanics, 394 nitroglycerin dobutamine stress echocardiography for, 206 in nonischemic mitral regurgitation, 76 tissue Doppler imaging for in cardiomyopathies, 392–393, 392f in diastolic function evaluation, 392, 392f in ischemic heart disease, 391 in left atrial function evaluation, 386–387, 387f pitfalls of, 389–391, 390f principles of, 389, 390f in right ventricular function evaluation, 393 strain rate measurement in, 206, 389 in valvular heart disease, 391–392 Myocardial hibernation, 201, 202f, 202t Myocardial infarction left ventricular free wall rupture after, 247 left ventricular thrombi after, 164–165 magnetic resonance imaging for scar imaging after, 232 mechanical complications of, 246–248 mitral regurgitation after, 248, 248t myocardial contrast echocardiography after, 231–232, 232f, 232t, 240 myocardial contrast echocardiography in for collateral flow evaluation, 241 contrast perfusion patterns in, 231, 232f, 232t for infarct size evaluation, 240, 241, 241f protocols of, 231, 232f for reperfusion assessment, 241 472 Index Myocardial infarction (Continued) for risk area detection, 240–241 myocardial perforation after, 246 no-reflow phenomenon after clinical implications of, 231, 232t imaging of, 232t papillary muscle rupture after, 248 pseudoaneurysm after, 247–248 right ventricular shock after, 246, 247f strain rate measurement in, 391 systolic murmur after, 248t ventricular septal defect after, 246, 247f Myocardial perforation, after myocardial infarction, 246 Myocardial performance index, 304 Myocardial rupture See Left ventricular free wall rupture Myocardial strain See Strain rate measurement Myocardial stunning, 201, 202f, 202t, 391 Myocardial tissue imaging See Myocardial evaluation Myocardial velocity (MV), 389 Myxoma See also Cardiac mass(es) atrial, 166, 166f, 266, 267f atypical, 271, 272f characteristics of, 166, 166f as embolic source, 166 natural history of, 267 treatment of, 267 N Nitroglycerin dobutamine stress echocardiography, 206 Noncompaction, left ventricular See Left ventricular noncompaction (LVNC) Nonischemic mitral regurgitation See Mitral regurgitation, nonischemic No-reflow phenomenon, 231, 232t O Occluder device, atrial septal, 269f Ostium primum, 440, 441f, 441t See also Atrial septal defect (ASD) Ostium secundum, 440, 441f, 441t See also Atrial septal defect (ASD) P Pannus in aortic prosthetic valves, 109 in mitral prosthetic valves, 113, 113f Papillary fibroelastoma, 271, 272f Papillary muscle dysfunction, 84 See also Mitral regurgitation, ischemic Papillary muscle rupture aortic valve abnormalities with, 273, 273f after myocardial infarction, 248 Parachute mitral valve, 58 Patent ductus arteriosus chest radiography of, 452 clinical presentation of, 451–452 computed tomography of, 453, 453f definition of, 451 echocardiography of, 452, 452f electrocardiography of, 452 embryology of, 451 epidemiology of, 438t, 451 incidence of, 439t in pregnancy, 453 transesophageal echocardiography of, 452, 453f treatment of, 453 Patent foramen ovale (PFO), 440, 441t versus atrial septal defect, 150, 150f clinical significance of, 151, 152f, 152t, 166–167 complications of, 149 definition of, 149 detection of, 149–150, 150t in Ebstein’s anomaly, 463f in elderly patients, 154 management of, 151–154, 153t, 154t prevalence of, 149 size of, 150–151, 166–167, 167t stroke risk with, 166–167 transesophageal echocardiography of, 166–167, 167f transthoracic echocardiography with agitated saline contract injection in, 166, 166t PE See Pulmonary embolism (PE) Pectinate muscles, versus atrial thrombi, 266, 268f, 277 Percutaneous mitral balloon valvulotomy, 53–54, 54t Pericardial cysts, 262–263, 263f Pericardial effusion echocardiographic assessment of, 250f grading of, 250 on hand-carried ultrasound unit, 397f loculated, 252, 285, 286f in primary pulmonary hypertension, 322 Pericardial tamponade acute, 252 anatomy and physiology of, 250 definition of, 250 echocardiographic assessment of, 250–251, 251f, 251t, 252f electrocardiography of, 251 hypertensive, 252 in left ventricular free wall rupture, 423 low pressure, 252 subacute, 252 variations of, 251–252 Pericardiocentesis, echocardiographic guidance of, 252 Pericarditis, constrictive See Constrictive pericarditis Pericardium congenital absence of, 262, 263f, 286, 288f imaging of, 286t Perimembranous ventricular septal defect, 448, 448f See also Ventricular septal defect (VSD) Persistent spongy myocardium See Left ventricular noncompaction (LVNC) PET (positron emission tomography), for myocardial evaluation, 203t, 204f, 205–206 Planimetry, for mitral valve area measurement, 50, 50f Pleural effusions, 252 Positron emission tomography (PET), for myocardial evaluation, 203t, 204f, 205–206 Posterior descending coronary artery, echocardiographic imaging of, 426 Pregnancy aortic dissection in, 171 coarctation of the aorta in, 460 Ebstein’s anomaly in, 464 patent ductus arteriosus in, 453 pulmonic stenosis in, 333 ventricular septal defect in, 449 Pressure half-time for aortic regurgitation measurement, 33, 120t for mitral valve area measurement methods for, 41, 42, 42f, 50–51, 50f pitfalls and limitations of, 59–60f, 59t Pressure recovery, with aortic prosthetic valves, 104–106, 105f Primary pulmonary hypertension clinical presentation of, 322 Doppler findings in, 322 echocardiographic findings in, 322–323 echocardiography for monitoring response to therapy, 323 epidemiology of, 322 structural abnormalities in, 322 Prosthetic heart valve(s) aortic See Aortic prosthetic valve(s) bioprosthetic, 108, 124, 125t, 126f complications of, 126–127, 129f embolism in, 166 evaluation of Doppler echocardiography in, 125 transesophageal echocardiography in, 125, 128f, 129f two-dimensional echocardiography in, 124–125, 127f, 129f mechanical, 108, 124, 125t, 126f mitral See Mitral valve repair/ replacement paravalvular leaks in clinical presentation of, 433 diagnosis of, 433–434, 434f etiology of, 433 percutaneous treatment of, 435–436, 435f surgical treatment of, 434–435 Proximal flow acceleration zone, for mitral regurgitation measurement, 66 Proximal isovelocity surface area (PISA) for aortic regurgitation measurement, 34, 34f for mitral regurgitation measurement, 67–68, 67f for mitral valve area measurement, 42–43, 43f, 51–52, 52f for tricuspid regurgitation measurement, 92, 93f Pseudoaneurysm aortic, 169, 170f in aortic prosthetic valves, 122 Pseudoaneurysm (Continued) contrast echocardiography for detection of, 377 ventricular, after myocardial infarction, 247–248 Pulmonary angiography, 324–325, 327f Pulmonary artery systolic pressure, exercise-induced changes in, 46, 47f Pulmonary embolism (PE) clinical presentation of, 324 diagnosis of computed tomography pulmonary angiography in, 325, 326f d-dimer assay in, 325 echocardiography in, 325–327, 325f, 326f electrocardiography of, 324, 325f pulmonary angiography in, 324–325, 327f ventilation-perfusion lung scan in, 325 epidemiology of, 324 pathophysiology of, 324 treatment of, 327–328 Pulmonary hypertension, in mitral stenosis, 54, 54f Pulmonary vein flow profile in diastolic function evaluation, 343–344, 350, 351f stenosis after atrial fibrillation ablation, 132, 133f, 134f tumor infiltration to atria via, 267, 270f Pulmonic stenosis clinical presentation of, 330 diagnosis of cardiac catheterization in, 331 chest radiography in, 331 echocardiography in, 331, 331f, 332f electrocardiography of, 331, 331f physical examination in, 330–331 epidemiology of, 330 etiology of, 330 pathophysiology of, 330 in pregnancy, 333 treatment of, 331–333, 332f, 333f Pulmonic valve in carcinoid heart disease, 318–319, 319f functional evaluation of, 338–339 morphology of, 338–339 Pulsed wave Doppler imaging in constrictive pericarditis, 256, 257f in left ventricular diastolic function evaluation, 351 Index in left ventricular dyssynchrony evaluation, 360–362, 361f, 362f in left ventricular outflow tract assessment, 296 in prosthetic aortic valve evaluation, 110, 120 in restrictive cardiomyopathy, 259–260, 260f in tricuspid regurgitation evaluation, 94, 95f Pulsus paradoxus, 252 Q Quadricuspid aortic valve, 2, 4f, 4t, 5t R Real-time three-dimensional echocardiography See Three-dimensional echocardiography, real-time Restrictive cardiomyopathy clinical characteristics of, 255t, 258, 259 computed tomography in, 260 versus constrictive pericarditis, 254, 255t, 258 demographics of, 258 echocardiographic findings in, 255t, 259–260, 259f, 260f magnetic resonance imaging in, 260, 260f myocardial biopsy in, 261 pathophysiology of, 258– 259 treatment of, 261 Reverse remodeling, after cardiac resynchronization therapy, 355–356 Rhabdomyoma, atrial, 266 Rheumatic heart disease, mitral valve changes in, 48 Right atrium functional evaluation of, 338 morphology of, 338 Right ventricle functional evaluation of, 337–338, 393 morphology of, 337 Right ventricular dysplasia, arrhythmogenic, 320–321 Right ventricular shock, after myocardial infarction, 246, 247f S Sarcoidosis, cardiac, 260f Sarcoma, atrial, 267 Single-photon emission computed tomography (SPECT) versus exercise echocardiography, diagnostic accuracy of, 194–196 for myocardial evaluation, 203t, 204f, 205 no-reflow phenomenon on, 232t Sinus venosus, 440, 441f, 441t See also Atrial septal defect (ASD) 60/60 sign, 326–327 Speckle tracking in left ventricular dyssynchrony assessment, 372, 373f in left ventricular systolic function evaluation, 346, 347f, 348 in left ventricular torsion mechanics assessment, 394 in myocardial velocity and strain calculation, 386, 388f Spontaneous echocardiographic contrast (SEC), 158–159, 159f Square root sign, 260 St Jude mitral valve prosthesis transesophageal echocardiography of, 129f two-dimensional echocardiography of, 124–125, 128f Starr-Edwards valve, mitral, 124, 127f Statins, in aortic stenosis, 25–26 “Steal” phenomenon, 222 Strain rate measurement in cardiomyopathies, 392–393, 392f in dobutamine stress echocardiography, 206, 210–212, 211f, 391 in ischemic heart disease, 391 pitfalls of, 389–391, 390f principles of, 389, 390f in right ventricular function evaluation, 393 in valvular heart disease, 391–392 Stress echocardiography diastolic, 213–214, 214f dobutamine See Dobutamine stress echocardiography (DSE) enoximone, 206 exercise See Exercise echocardiography nitroglycerin dobutamine, 206 perfusion agents for, 222 prognostic value in coronary artery disease, 216–217, 217f, 218–219, 219f three-dimensional echocardiography in, 383, 412–413, 413f Stroke aortic plaque and, 181–182 473 atrial fibrillation and, 158, 159t patent foramen ovale and, 151–152, 152t, 153t, 154t Stroke volume, aortic, 31 Subaortic stenosis diagnosis of, 14–15 cardiac catheterization in, 15–16 echocardiographic findings in, 14–15, 15t indications for surgery in, 15t, 17 morphologic variants of subaortic membrane in, 14, 15f, 15t, 16f natural history of, 15t, 16 pathophysiology of, 16 Sudden cardiac death in athletes with arrhythmogenic right ventricular dysplasia, 320 with hypertrophic cardiomyopathy, 292, 293f in severe aortic stenosis, 22 Supracristal ventricular septal defect, 448, 448f See also Ventricular septal defect (VSD) Systolic annular velocity, 343f Systolic function See Left ventricular systolic function T Takotsubo cardiomyopathy clinical findings in, 306, 308t, 404, 404f, 405t demographics of, 306, 404 diagnosis of, 306 echocardiography in, 307f, 405f electrocardiography of, 307f, 405f myocardial contrast echocardiography in, 307f pathophysiology of, 306, 308, 308t, 404 prognosis of, 404 three-dimensional echocardiography in, 405f treatment of, 306 TDA See Traumatic disruption of the aorta (TDA) TEE See Transesophageal echocardiography (TEE) Tei index, 304 Tetralogy of Fallot characteristics of, 446 incidence of, 439t Thallium SPECT See Singlephoton emission computed tomography (SPECT) 474 Index Theophylline, 222 Thoracic aorta, artifacts of, 278 Three-dimensional echocardiography in aortic regurgitation, 35 clinical impact of, 184 development of, 381 in dilated cardiomyopathy, 311–312, 312f, 313f, 314f, 315f in left ventricular dyssynchrony evaluation, 365, 367f, 368f in left ventricular infarct exclusion surgery, 145–146 in mitral stenosis, 43, 43f in mitral valve repair/ replacement, 73, 73f real-time, 381 future directions, 385 in ischemic mitral regurgitation, 139, 140f, 384 in left ventricular asynchrony, 384–385, 384f in left ventricular noncompaction, 401, 401f in left ventricular parameter evaluation, 381–382, 383f in mitral stenosis, 55, 55f, 384 of right ventricle, 338 in stress testing advantages of, 412–413 limitations of, 413 methods for, 412, 413f in Takotsubo cardiomyopathy, 405f Thromboembolism See Embolism Thrombosis in aortic prosthetic valves, 109 in mitral prosthetic valves, 112–113, 113f Thrombus apical, contrast for detection of, 376 atrial, 266, 268f, 288f in dilated cardiomyopathy, contrast injection for detection of, 316, 316t Time velocity integral (TVI), in tricuspid regurgitation, 93, 93f Tissue Doppler imaging See also Pulsed wave Doppler imaging in arrhythmogenic right ventricular dysplasia, 321 in constrictive pericarditis, 256–257, 257f with dobutamine stress echocardiography limitations of, 212 positive and negative aspects of, 210t principles of, 208–210, 209f strain rate measurement in, 206, 210–212, 211f with hand-carried ultrasound unit, 396f in left ventricular diastolic function evaluation, 351, 352f in left ventricular dyssynchrony assessment, 362–363, 363f, 364f, 365f, 371–372 myocardial See Myocardial evaluation, tissue Doppler imaging for in restrictive cardiomyopathy, 260, 260f Tissue synchronization imaging, 363, 366f, 372, 373f Trabeculations, 376 Transcranial Doppler, in patent foramen ovale, 149–150 Transesophageal echocardiography (TEE) in aortic dissection, 172f, 173, 173f, 173t, 174 in aortic intramural hematoma, 177, 177f in aortic plaque, 167, 167f, 180, 181f in aortic prosthetic valve evaluation, 111, 111f, 120–121, 120f, 128f in aortic regurgitation, 35 of aortic root abscess, 170f of aortic root pseudoaneurysm, 170f in aortic stenosis, 11–12, 12t in atrial fibrillation ablation, 132, 133f, 134f in atrial fibrillation cardioversion, 160–161, 160t, 161t in atrial fibrillation evaluation, 158–160, 159f in atrial septal defect, 444–444 of bicuspid aortic valve, 6–7, 7f clinical impact of, 183–184 in constrictive pericarditis, 285, 286f in cor triatriatum, 58 with hand-carried ultrasound unit, 396f in infective endocarditis, 169 intraoperative in atrial fibrillation ablation, 132 of ischemic mitral regurgitation, 139–141, 140f in mitral valve repair/ replacement, 143–144 of left atrial appendage, 135, 136f, 137f in left ventricular free wall rupture, 421 in left ventricular infarct exclusion surgery, 147f in loculated pericardial effusion, 286f in mitral prosthetic valve evaluation, 114, 115f, 116–118, 117f, 128f in mitral regurgitation, 63, 63f for assessment after valve repair/replacement, 72–73 for guidance during valve repair/replacement, 71–72, 139–140, 140f for preoperative assessment, 71, 72f in mitral stenosis, 45, 54–55 in mitral valve prolapse, 142–143, 143f of paravalvular leaks in prosthetic valves, 433–434, 434f of patent foramen ovale, 149–150, 150t, 166–167 in pulmonary embolism, 327 of right ventricle, 338 in traumatic disruption of the aorta, 417, 418f, 418t, 419f in tricuspid regurgitation, 91–92 Transmitral pressure gradient, 342 Transposition of the great arteries, 455 See also Congenitally corrected transposition of the great arteries Transverse sinus, fluid in, 277 Traumatic disruption of the aorta (TDA) versus aortic dissection, 418t diagnosis of, 417, 418t pathophysiology of, 418 risk factors for, 417, 418t transesophageal echocardiography in, 417, 418f, 418t, 419f treatment of, 417, 419t Treadmill, for exercise echocardiography, 189 See also Exercise echocardiography Tricuspid annulus in Ebstein’s anomaly, 462, 463f fat infiltration of, 277 Tricuspid annulus velocity, 386f, 387 Tricuspid regurgitation in carcinoid heart disease, 317–318, 317f, 318f with congenitally corrected transposition of the great arteries, 456, 457f etiology of, 90–91, 91f evaluation of color flow Doppler for, 92–93, 93f continuous wave Doppler for, 94, 95f pulsed wave Doppler for, 94, 95f transesophageal echocardiography in, 91–92 two-dimensional echocardiography in, 91–92 after mitral valve replacement, 96 natural history of, 94–96 prevalence of, 90 in primary pulmonary hypertension, 322 surgical management of, 96 valve morphology in, 90, 91f Tricuspid valve anomalies associated with congenitally corrected transposition of the great arteries, 455–456 functional evaluation of, 338 morphology of, 338 prosthetic, echocardiographic evaluation of, 125, 128f Trypanosoma cruzi, 407 See also Chagas cardiomyopathy Turner syndrome, coarctation of the aorta in, 460t TVI (time velocity integral), in tricuspid regurgitation, 93, 93f U Unroofed coronary sinus, 441, 441t See also Atrial septal defect (ASD) V Vasodilator stress perfusion testing, with myocardial contrast echocardiography, 222–224, 223f, 224f See also Myocardial contrast echocardiography (MCE) Vena contracta width in aortic regurgitation, 33, 35t, 120t in tricuspid regurgitation, 93–94, 94f Ventilation-perfusion lung scan, 325 Ventricular dyssynchrony See Left ventricular dyssynchrony Ventricular free wall rupture, after myocardial infarction See Left ventricular free wall rupture, after myocardial infarction Ventricular septal defect (VSD) atrial fibrillation and, 248t chest radiography in, 447 Index clinical presentation of, 446–447 with congenitally corrected transposition of the great arteries, 455 echocardiography of, 447–448, 448f electrocardiography of, 447 epidemiology of, 438t, 446, 447t incidence of, 439t after myocardial infarction, 246, 247f pathophysiology of, 446 in pregnancy, 449 treatment of, 449 types of, 446 475 W Watchman device, for left atrial appendage closure, 136f Westermark sign, 324 Women, exercise echocardiography accuracy in, 189–190 This page intentionally left blank Instructions for online access Thank you for your purchase Please note that your purchase of this Elsevier eBook also includes access to an online version Please click here (or go to ebooks.elsevier.com) to request an activation code and registration instructions in order to gain access to the web version ... echocardiography with 20 1Tl single-photon emission computed tomography Circulation 91 :27 48 -27 52, 1995 24 Bonow RO: Identification of viable myocardium Circulation 94 :26 74 -26 80, 1996 25 Pierard LA, De... Probl Cardiol 26 :147-186, 20 01.) 100 78% 90 80% Sensitivity Functional recovery % 100% EF Ն 30% 83 80 Thallium SPECT 48 PPV 93 88 86 Specificity 60% 40% 20 % 61 22 % 23 80 LDDE 70 FDG PET 20 % 39 36... Coll Cardiol 43 :22 42- 224 6, 20 04 10 McCully RB, Roger VL, Mahoney DW, et al: Outcome after normal exercise echocardiography and predictors of subsequent cardiac events: follow-up of 1 325 patients