The Cardiac Sonographer CME system is undergoing testing. ONLY CARDIAC SONOGRAPHY CME RESULTS ARE INVALID. AMA CME is valid.
Case of the Week
Discussion>Case of the Month>1
Case-of-the-Week Information
The Case-of-the-Month is a presentation of one or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).
You can change the size and the format of the image or video loops by using the links below the image or video loop.
= Windows Media Video
= MP4 Video
= QuickTime
= WebM Video
= Flash
= JPG Image
Video Sizes
= GIF Image
1X = 200x150 pixels
2X = 400x300 pixels
3X = 6000x450 pixels
4X = 800x600 pixels
Loop Text Key
Preop
Preop TEE or TTE
Intraop
An Intraop TEE
IntraopPreOp
Intraop TEE before Operation
IntraopPostOp
Intraop TEE after Operation
IntraopEnd
Intraop TEE at End of Anesthesia
Post Op
Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
CAD, CHF, and More?
Case#: 20
AMA CME Units: 0.25 Units CME Requirements: Active CME Session and must be a paid, active subscriber to iTEE or advanced TEE AND have enough CME credits in your bank. AMA CME ONLY.
Presentation: 62 y.o. female with history of CAD, MI, HTN, Renal Insufficiency, IDDM, and Depressed LVEF
Cardiac Cath: LAD 50%, D1 99%, Ramus 99%, RCA 60%
What is your assessment of the echo exam?
What is your assessment of the LAP, MR, and RV function?
Does the patient have diastolic dysfunction of the left ventricle?
Does the patient have diastolic dysfunction of the right ventricle?
Loops:
Case Discussion/CME Questions
The echo exam shows akinesis of the anterolateral wall, the mid/apical portion of the right ventricle, the apical portion of the interventricular septum, the mid/apical portion of the anterior wall, the mid/apical portion of the inferoseptal wall, and hypokinesis of the anteroseptal and inferolateral walls.
All four chambers are dilated. There is mild mitral regurgitation, moderate tricuspid regurgitation, trace pulmonary regurgitation, trace of aortic regurgitation and aortic sclerosis of the left coronary cusp,
The measurements show the following:
MR Jet Area: 5.49 cm2
LA Diameter: 4.30 cm
AV Vmax 1.65 m/s, VTI 34.9 cm
LVIDd 6.64 cm, LVIDs 6.55 cm
LVI E velocity 1.15 cm/sec, DT 200 msec, A velocity 32.6, A dur 150 msec
LV CMMVp 40.4 cm/sec
Septal TDI S' 5.10 cm/sec, E' 5.00 cm/sec, A' 4.59 cm/sec
AVA by 2D 2.60 cm2
LVOTd 1.86 cm
Pulmonary Vein S 37.1 cm/sec, D 84.4 cm/sec, A 39.5 cm/sec, A dur 170 msec
RVI E 51.4 cm/sec, A 65.3 cm/sec
RV CMMVp 42.9 cm/sec
IVC Expiration 2.24 cm, Inspiration 2.21 cm
RVOTd 1.75 cm
PV Vmax 88.7 cm/sec, VTI 17.7 cm
Using the duration of the pulmonary vein and LVI A waves, the PCWP is 20.2 mmHg.
Using the LVI E Vmax and the TDI E Vmax, the PCWP is 35.3 mmHg.
Using the CMMVp and LVI E Vmax the PCWP is 20.1 mmHg.
The RAP appears high also from the lack of IVC collapse and since the interatrial septum remains deviated towards the LA throughout the cardiac cycle, the RAP is greater than the LAP.
The LVEF calculates out to less than 10%. The SV is 94.7 mls.
The pulmonary vein pattern suggests elevated LAP and moderate/severe mitral regurgitation.
By CMMVp the left ventricle does not have diastolic dysfunction.
The RV E-to-A ratio was less than 1 and in patients with left ventricular heart failure, the E-to-A ratio was near 0.9 in one study. The E DT in the study was also prolonged as was the IVRT, especially with pulmonary hypertensiont (the IVRT and DT of the RV could be due to the pulmonary hypertension although differences were seen in patients without pulmonary hypertension). There are no articles on CMMVp for the RV that we could find on pubmed.
The LV DT is 200 msec which is inconsistent with moderate or severe diastolic dysfunction. However, the E Vmax and pulmonary vein systolic suppression and increased pulmonary vein A wave velocity are consistent with moderate/severe MR. Since the LVEF is very low, given a normal LVEF, the MR would most likely be severe.
Our assessment of the LV and RV function is that the LVEF and RVEF are severely depressed. The LVEF depression is obvious from all of the akinetic segments that are present. The RV systolic dysfunction is not as evident given that TAPSE appears almost normal. However, there is an akientic portion of the RV wall that is viewable on some nonstandard views. The akinetic wall could be due to severe pulmonary hypertension but the pulmonary artery pressure was not calculated.
Please answer the following questions correctly to obtain your CME.
= Windows Media Video
= MP4 Video
= QuickTime
= WebM Video
= Flash
= JPG Image
= GIF Image
