Echo Potpourri Part III: Case, Cases, and More Cases!

Jeffrey C. Hill, BSBA, ACS, FASE

Chair, Joint Review Commission on Education in CVT

Program Director, Clinical Coordinator, School of CVT

The Hoffman Heart & Vascular Institute of CT

Saint Francis Hospital, Hartford, CT

Disclosures

• Philips Healthcare: Consultant

• 53 y/o female• S/P arrest• New LBBB• ICD Placement• No valvular dz• EF = “50 ish”

GLS & TTP

• 36 y/o male

• Marked fatigue

• Joint pain

• Pedal edema

• Significant weight gain

• New DOE walking the dog

• Pt notes “Change in complexion”

Ferritin = 5,556 mL/pg

Baseline 12 month f/uFerritin = 145 mL/pg

GLS = -11% GLS = -21%

EDV = 175mL EDV = 127mL

ESV = 129 mL; EF = 26% ESV = 52 mL; EF = 59%

Diastology Work-Up

E wave = 59 cm/sA wave = 26 cm/sE decel = 143 ms

E wave = 89 cm/sA wave = 31 cm/sE decel = 190 ms

Baseline 12 month f/u

E’ = 7 cm/sA’ = 4 cm/sS’ = 4 cm/s

E’ = 10 cm/sA’ = 7 cm/sS’ = 7 cm/s

Baseline 12 month f/u

HR = 60 BPM HR = 61 BPM

S wave = 56 cm/sD wave = 38 cm/s

S wave = 78 cm/sD wave = 74 cm/s

Baseline 12 month f/u

Image Adapted and Modified From: Phelan et at. J Am Soc Echocardiogr 2014;27:888-95.

HCM

CA

HHD

Image Adapted and Modified From: Phelan et at. J Am Soc Echocardiogr 2014;27:888-95.

HCM CA HHD

Name That Disease

• 71 y/o male

• LBBB

• Hx of CM, HTN

• New syncope, progressive increase of SOB

• Note: synchronized ventricular contraction in the presence of wide QRS

Image adapted and modified from: Jarcho JA N Engl J Med 2005;352:1594

Biventricular Pacing: The 3rd Wire

3rd wire in coronary sinus

RA lead

CS ostium

RV lead

CS lead

A4 coronary sinus view

P V

PACED

PP

Synchronize time of atrial

systole and onset of LVP

Goal: improve AV synchrony, “recruit preload”, ↑ (+) dP/dt,

pulse pressure (PP) and stroke volume

Image courtesy of Alan Waggoner

Onset of

LVP systole

Aortic

pressure

Peak

atrial systole

P R

INTRINSIC

PP

Delay to onset of LVP

Left ventricular

pressure (LVP)

Before CRT 3 months after CRT

NONRESPONDER

Presenting A-V Delay = 100/130 ms

Restrictive filling

E

A

E A

Before

A-V Delay = 100 ms

After

A-V delay = 180 ms

Stage III filling pattern

A-wave truncation

Stage II/I filling pattern

Complete A-wave contribution

A-V Delay 100 ms

VTI = 19 cm A-V delay 180

Optimized VTI = 24 cm

• 58 y/o male

• Ischemic CM

• Dyspnea at rest

• Pedal edema

• Significant weight gain

• PASP = 60-65 mmHg

• “Quadrachamber” failure

4 Years After CRT

Baseline