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AMA PRA Category 1 Credit(s)TM for Physicians Only.
ASRT CME Not Available
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).

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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
Do you need a Para?
Case#: 47
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes
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: 65 y.o. male with hx of Angina who now presents for a CABG.
The patient chews tobacco for 30 years.
The heart cath shows a LAD 100%.
The operation was a LIMA -> LAD, fRIMA -> D3

Please review the echo exam.

Questions to consider are:

What is your assessment of the left ventricular systolic function?
What is your assessment of the left ventricular filling pressures?
What is your assessment of the left ventricular diastolic function?
Discuss the impact of the parametric wall motion analysis on the interpretation of RWMAs?

Case Discussion/CME Questions
The TEE showed:

The LVEF is 40%. The apex is HK. The mid Anteroseptal wall is AK.
Parametric showed anterior, anteroseptal, some septal AK
LVEDD 5.19 cm, LVESD 3.70 cm
 The RVEF is 50%.
LVI: The E is 83 cm/sec, DT 246 msec, IVRT 95 msec,A 44 cm/sec, Adur(158 msec), E/A = 1
TDE: The S` is 5.8 cm/sec, E` 9.1 cm/sec, A` 14.9 cm/sec
PVn: The S is 53 cm/sec, D 44 cm/sec, A 20 cm/sec (Adur 116 msec)
The CMMVp is 35.3 cm/sec.
The Desc Ao Grade 3, AscAo Grade 2 by TEE, Grade 4 by EA
AV Vmax 1.16 m/sec, pAVG 5 mmHg, mAVG 2 mmHg. AVA by 2D TEE 2.7 cm2.
TR Vmax 2 m/sec
Lambl's Excressence was present.
A moderator band was present.

The PCWP by Adur/Adur is 10 mmHg. The PCWP by DT is < 10 mmHg.
The CPCWP by TDE E/LVI Emax = 14.9 mmHg.
The LAP by Emax/Vp = 16.9 mmHg.

Parametric imaging, which is the conversion of a 3D loop to a still frame showing the
initiation(timing) of wall excursion and the amount/direction of wall excursion, can impact
the interpretation of a TEE. Toledo, Angelini, and others showed that parametric imaging of the
left ventricle is accurate with an acceptable senstivity and specificity rate.
Kachenoura showed that the time to first contraction
are delayed in hypokinetic (150 msec) and akinetic (200 msec) segments more than normal (100 msec) segments.
The  mean contraction time showed the same delay pattern. The radial velocity was also lowered for
akinetic (1 cm/sec) segements and hypokinetic (2 cm/sec) more than normal segements (3 cm/sec).
Caiani showed that inexperienced echocardiographers improved
their accuracy more but did not become more accurate than experience echocardiographers when
parametric images were added to the exam (animal study). Kachenoura showed that in patients
with poor acoustic windows, using parametric images along with contrast, improved the
accuracy of RWMA diagnosis in inexperienced users.

Myocardial dyssynchrony can be difficult to appreciate when the delay is less than 80 msec.
Parametric imaging shows an image of the onset of contraction for segments where the amount of
delay is easier to visualize and will even point out the segments that are delayed and the degree
of the delay. While the posterolateral wall is the usually wall that is delayed in a wide QRS and decreased
LVEF, O'Mara showed that this is not always the case and segments or the delay of segmental contraction can
be delayed or improperly treated with a biventricular pacer with improper lead placement. Also, if multiple segments
are delayed, the parametric image will help decipher where to place the leads to achieve maximum benefit.

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