June 11/12, 2014 - Jonathan Go - Cardiology - Echocardiography

June 11 and June 12, 2014

  These past two days have been filled with a lot Echocardiography with Dr. Wang and Dr. Huang.  We used Echo to evaluate 40 plus patients.  The following entry will be a record of notable cases and things that I learned. 

First for the interesting cases:

Case 1:  34 year old Taiwanese male who presents with dyspnea upon exertion.  On echo, the right atrium and right ventricle was dilated.  Also noted a fixed S2 split on auscultation.  Further in the examination we noted an Atrial Septal Defect.  This would explain the dilation of the right atrium and ventricle (increased preload from the left to right shunt would lead to dilation of the left atrium and of the left ventricle).  We visualized the ASD on a short axis view.  A long axis view can be used to visualize a ventricular septal defect.  A four chambered view can visualize a ASD or VSD.  Interesting to note:  Dr. Wang said that he only sees a couple ASD cases a year.  Also he found a patent ductus arteriosus last week in a 70+ year old female.

Case 2:  In the middle of our Echocardiography session, Dr. Wang recieved a phone call from the ER regarding a patient that came in.  This patient is a 92 year old Taiwanese female who has ongoing loss of conciousness that began 5 hours ago.  The past few days she has been experiencing vertigo, nausea, and vomitting.  She has an elevated Troponin at  a value of 1.  She has a PMH of diabetes, hypertension, and CKD.  She has a metabolic acidosis.  On EKG she has inferolateral heart ischemia.  Her echo on her heart came back normal for the most part.  She is unresponsive to neurologic stimuli but responds intermittantly.  Neurologist says that stroke is unlikely; however, at the same time MI is also ulikely from EKG and Echo.  What can be causing this?  For now we have to wait for the MRI; however, from CT we know there are no neoplasms in the brain.  So at this point we are thinking possible meningitis or pharmaceutical effects.  Hopefully we find out tomorrow.

Case 3:  56 year old Taiwanese male who suffered a stroke 2 months ago and who has a PMH of DM 2 (controlled), hyperlipidemia, and hypercholesterolemia.  When he suffered a stroke, personel discovered heart disease. Patient suffers CHF with the left Atrium Dilated.  What most likely occurred was A.fib --> thrombus formation --> embolization to systemic --> stroke.  It is interesting to note here that in the last blog I talked about how medicine in Taiwan does not routinely prescribe thrombolytics even if the patient has A.fib.

Interspersed throughout the rest of the cases were a lot of Mitral Regurgitation, Tricuspid Regurgitation, Aortic Regurgitation, and Mitral Valve Prolapse.  Almost all of these cases had these valvular diseases but present at minor grading.  We saw a variety of patients, young to old, with indications ranging from serious to precautionary.

Some things that I learned:

• Visualize an ASD in short axis parasternal view or four chambered view
• Visualize a VSD in long axis view or four chambered view
• Pericardial effusion due to bacterial cause can organize and lead to septated pericarditis
• Examine the IVC on echo
• Euvolemic --> collapsed IVC
• Blood backing up (like in HF) --> Enlarged IVC
•  Detecting a Diastolic Dysfunction using Doppler:
• Place cursor at the level of the openning leaflets of valve in diastole
• E wave represents filling velocity in early diastole
• A wave represents filling velocity in late diastole
• In healthy heart E wave shoudl be larger than A wave
• As ventricle stiffens or filling is impaired E wave will decrease and A wave will increase
• This indicates a Diastolic Dysfunction using doppler