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Role of Echocardiography in Acute Chest Pain Syndromes in the Era of Multimodality Imaging Ernesto E Salcedo, MD Professor of Medicine university of Colorado Denver Director of Echocardiography University of Colorado Hospital Main causes of chest pain that pose an immediate threat to life • • • • • • Acute coronary syndrome Acute Aortic Syndromes Pulmonary embolism Tension pneumothorax Pericardial tamponade Mediastinitis (eg, Esophageal rupture) To Admit or Not to Admit • Patients with acute myocardial infarction who are mistakenly discharged from the emergency department have short-term mortality rates of about 25 percent, at least twice what would be expected if they were admitted Lee TH NEJM 2000 • The admission of a patient with chest pain who is at low risk for acute myocardial infarction costs an average of $5,000 at many institutions and can lead to unnecessary tests and procedures, with their attendant costs and complications * Nuclear Stress Test Courtesy Dr. J Maloo, University of Colorado Denver Stress Echocardiogram bod-ron 00012589 Left Ventricular Segmental Wall Motion Analysis Lang R J Am Soc Echocardiogr 2005;18:1440-1463. Segmental LV Wall Analysis Hutchison SJ 2009 Complications of Myocardial Infarction Regional Wall Motion Abnormalities Parametric Imaging- Dyssynchrony Methods: RT3DE (Philips) and CMR (Siemens) images were obtained from 31 patients and analysed by using prototype software to semiautomatically calculate indices of regional left ventricular function, which were compared between RT3DE and CMR (linear regression, Bland–Altman). Additionally, CMR images were reviewed by an expert, whose RWM grades were used as a reference for automated classification of segments as normal or abnormal from RT3DE and from CMR images. For each modality, normal regional ejection fraction (REF) values were obtained from 15 patients with normal wall motion. In the remaining 16 patients, REFs were compared with thresholds that were derived from patients with normal wall motion and optimised using receiver operating characteristic analysis. Nesser HJ Heart 2007;93;572-578 Segmental Wall Motion Analysis 3D Echo vs. CMR Nesser HJ Heart 2007;93;572-578 Coronary CT Angiography Courtesy Dr. J Maloo, University of Colorado Denver Sf-rca8/08 sten-42yo2052273 8-8 2052273 CT Angiogram Patent SVG to LAD Courtesy Dr. J Maloo, University of Colorado Denver KJ-CABG-06-11 Case ACS_139 CT Angiogram Patent STENT LAD Courtesy Dr. J Maloo, University of Colorado Denver * 3D LV Size and function Full Volume Live 3D LV Shell and Segments Multiplane reconstruction LV Volumes and EF by 3D Echo Dorosz J….Salcedo E JACCC 2012 in press Meta-analysis of Echo vs. CMRI LV Volume and EF Dorosz J….Salcedo E JACCC 2012 in press Comparison of end-diastolic volume (mL), end-systolic volume (mL) and ejection fraction (%) measured by magnetic resonance imaging and echo measures Accuracy Narrowing of the Limits of agreement With each additional modality 2D 3D Jenkins C. European Heart Journal (2009) 30, 98–106 * * Apical Akinesis at Rest No New Segmental Wall motion Abnormalities * * * * Global Ischemia Courtesy Dr. J Maloo, University of Colorado Denver Fesseh_F-dit-1520317 Inferior Scar Anterior Ischemia Inferior Scar Anterior Ischemia ACUTE AORTIC SYNDROMES Aortic Dissection Classification Classic Aortic Dissection Ulceration Intramural Hematoma Discrete Dissection From Svensson LG, Circulation 99: 1331–6, 1999 Iatrogenic Dissection European Heart Journal (2001) 22, 1642–1681 Echocardiography in Aortic Dissection • Transesophageal echocardiography in addition to transthoracic echocardiography can be used for decision making in the emergency room or even operating theatre in acute aortic dissection with high accuracy. • Pitfalls have to be taken into account. • The high resolution enables the diagnosis also of intramural hematoma, plaque ulceration, as well as traumatic aortic injury. When more spatial resolution is necessary, CT or MRI are used in addition. European Heart Journal (2001) 22, 1642–1681 Arch aneurysm with dissection flap. Jacobs AK Circulation. 2010;121:1544-1579 Artifact mimicking dissection. Jacobs AK Circulation. 2010;121:1544-1579 Conclusions: TTE is a useful imaging modality for the diagnosis of acute type A aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room, whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis. Am Heart J 2012;163:112-8 Conclusions • Echocardiography plays a central role in the management of acute chest pain syndromes. • Transthoracic echocardiography provides critical information for the diagnosis and risk stratification of patients with suspected or known ACS. • TEE and to a lesser degree TTE are key imaging tools in the diagnosis and management of Acute Aortic Syndromes. [email protected]