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Mitral Stenosis

Echocardiography plays a key role in the assessment of the severity and consequences of mitral stenosis (MS). Echocardiographic analysis of valve anatomy is used to differentiate rheumatic heart disease from other causes and to select the most appropriate intervention, particularly with regard to balloon mitral commissurotomy (BMC) in cases of rheumatic MS and transcatheter mitral valve replacement (TMVR) in cases of degenerative MS. The large experience…

Transcatheter Mitral Valve Repair

Despite the reduced incidence of rheumatic heart disease, the prevalence of mitral regurgitation (MR) is increasing and is anticipated to continue to increase as the population ages. The management of advanced valvular heart disease, once the unique domain of cardiac surgery, is being supplemented or replaced in certain patient populations by nonsurgical or hybrid catheter-based interventions. The 2020 AHA/ACC Guidelines for Management of Patients with Valvular…

Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation

The superiority of mitral repair over replacement for treating primary mitral regurgitation (MR) is well established. , In appropriately selected patients, mitral repair is also optimal for treating secondary MR. Transesophageal echocardiography (TEE) is ideal for identifying reparable mitral valve disease and guiding surgical repair. , This chapter focuses on the use of TEE to guide surgical repair and to identify complications after repair. The indications…

Mitral Regurgitation: Valve Anatomy, Regurgitant Severity, and Timing of Intervention

Mitral regurgitation (MR) is a common valvular disorder that is a significant cause of morbidity and mortality in cardiovascular disease. Population studies have estimated the prevalence of mild or greater MR to be 20%. More than 30,000 patients undergo mitral valve (MV) surgery annually for significant (moderate or severe) MR in the United States. MR can be categorized as primary (valvular) or secondary (ischemic or functional).…

Aortic Regurgitation

Background Aortic regurgitation (AR) is characterized by diastolic reflux of blood from the ascending aorta into the left ventricle (LV). The clinical presentation varies and depends on several factors, including acuity of onset, aortic and LV compliance, hemodynamic conditions, and severity of the lesion. The overall prevalence of chronic AR is 5% to 10%, with most cases classified as trace or mild. Moderate or severe AR…

Aortic Stenosis (Including Evaluation for Transcatheter Aortic Valve Replacement)

Disease Stages Aortic stenosis (AS) is the most common valvular heart disease in developed countries. Aortic sclerosis, the precursor of AS, occurs in more than 25% of patients older than 65 years of age. The prevalence of AS increases with age and is about 3% among patients older than 75 years of age. With an aging population, the widespread use of echocardiography, and percutaneous treatment options,…

Role of Echocardiography in Patients With Acute Coronary Syndrome

Applicable Modes of Echocardiography in the Coronary Care Unit Transthoracic echocardiography (TTE) is ideally suited for cardiac imaging in the coronary care unit. It offers major advantages compared with other imaging modalities, including its portability, its relative low cost, and the wealth of anatomic, hemodynamic, and functional information that can be obtained rapidly at the bedside. With further technologic advances, it continues to play a major…

Nonexercise Stress Echocardiography for Diagnosis of Coronary Disease

Stress echocardiography (SE) is a mainstay of ischemic heart disease diagnosis and risk stratification. For diagnosis of coronary artery disease (CAD), various stressors (e.g., exercise, pharmacologic agents, pacing) are used to create an imbalance between oxygen supply and demand, resulting in myocardial ischemia. The induction of ischemia progresses from impaired perfusion and metabolic changes to regional systolic dysfunction (manifesting as wall motion abnormalities [WMAs]), electrocardiographic changes,…

Stress Echocardiography for Detecting Coronary Ischemia

Exercise Echocardiography for the Diagnosis of Coronary Disease Stress echocardiography—exercise or pharmacologic stress electrocardiography (ECG) coupled with echocardiography—is the most specific and sensitive method to noninvasively identify patients with inducible myocardial ischemia due to coronary artery disease (CAD) without the use of ionizing radiation. As early as 1935, Tennant and Wiggers demonstrated that coronary occlusion impairs myocardial contraction. In the 1970s, studies showed that regional wall…

Cardiac Tumors and Cardio-oncology

Cardio-oncology is a growing field aimed at recognizing, monitoring, and treating cardiovascular complications resulting from cancer and cancer-related treatments. Echocardiography plays an essential role in the baseline assessment and serial follow-up of oncology patients and remains the test most often used to evaluate cardiac function in patients of all ages who undergo a variety of anti-cancer therapies. Although several echocardiographic variables are capable of evaluating systolic…

Pericardial Disease

Although relatively few in number, pericardial diseases have a multitude of causes ( Table 17.1 ) and may have life-threatening effects. They frequently masquerade as other diseases and may be missed if not considered in the differential diagnosis. Treatments are usually available if the condition is correctly diagnosed. For these reasons, pericardial diseases have long fascinated the medical community. Constrictive pericarditis, pericardial effusion and tamponade, and…

Cardiac Assist Devices

Mechanical circulatory support (MCS) in the form of cardiac assist devices plays an increasingly important role in the treatment of end-stage cardiac disease. Extracorporeal membrane oxygenation (ECMO) devices developed in the middle of the 20th century enabled cardiopulmonary bypass and subsequent advances in cardiac surgery. ECMO began to be used outside of the operating room for temporary support of children with ventricular failure. A permanent heart…

Cardiac Transplantation

Since the first human heart transplant operation in 1967, the field of advanced heart failure and cardiac transplantation has continued to grow, with more than 5500 heart transplantations performed annually worldwide in each of the past few years. Advancements in surgical technique, histocompatibility testing, and immunosuppression have led to improvements in graft longevity and patient survival. Because of its ready availability, low cost, and safety, echocardiography…

Restrictive Cardiomyopathy

Definition and Pathophysiology Restrictive cardiomyopathies (RCMs) are a heterogeneous group of heart muscle disorders that, in their advanced stages, are characterized by a marked increase in left ventricular (LV) myocardial stiffness. Clinically, this manifests as congestive heart failure, often in the setting of a normal left ventricular ejection fraction (LVEF). The reduction in LV compliance results in hemodynamic abnormalities and associated cardiac structural changes, both of…

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an uncommon, inherited form of heart disease whose cardinal feature is unexplained left ventricular hypertrophy (LVH), with or without obstruction of the left ventricular outflow tract (LVOT). , HCM was first described by British pathologist Donald Teare in 1958, who reported autopsy findings from a series of patients with sudden death and unexplained LVH that was initially and mistakenly described as a…

Dilated Cardiomyopathy

Classification of Dilated Cardiomyopathy Precise designation of the cardiomyopathies can be challenging. The World Health Organization (WHO) 1995 classification introduced the following broad categories of cardiomyopathy based on pathophysiology and clinical cause: dilated (DCM), hypertrophic, restrictive, arrhythmogenic RV, and unclassified. The WHO classification remains commonplace in clinical practice, and cases are efficiently stratified on the basis of imaging and descriptive parameters. The classification was revised by…

Focused Cardiac Ultrasound at the Bedside

Focused cardiac ultrasound (FoCUS) is a readily accessible and widely used tool for the bedside diagnosis of basic cardiac pathology. Long championed by emergency room and critical care physicians, point-of-care ultrasound (POCUS) in general, including FoCUS, is increasingly utilized by a range of providers, including physicians and advanced practice providers in both inpatient and outpatient settings across many specialties. FoCUS is emerging as a fundamental clinical…

Interventional Echocardiography

Structural heart disease involves pathology of the valves and various other cardiac structures. Many of these defects can be treated by image-guided transcatheter procedures, often involving rapidly evolving technologies that present new challenges and opportunities for the echocardiographer. As novel catheter-based procedures and technologies are developed, more interventional procedures are being performed, improving outcomes for patients with previously untreatable conditions. Ongoing periprocedural cardiovascular imaging plays a…

Intraoperative Echocardiography

The use of transesophageal echocardiography (TEE) in the operating room has evolved from a simple tool to look at ventricular wall motion to a powerful diagnostic modality for examining every facet of cardiac and noncardiac surgery. Its use has improved the quality of perioperative care. Intraoperative assessments of valvular function, chamber size, masses, and great vessels are covered in other chapters of this textbook. The milieu…

Comprehensive Diagnostic Transthoracic and Transesophageal Echocardiography

Echocardiography is the most commonly used imaging modality for the evaluation of cardiac anatomy and function; it allows comprehensive evaluation of left ventricular (LV) and right ventricular (RV) function, regional wall motion, valvular heart disease, and pericardial disease, as well as estimation of pulmonary pressures and central venous pressure. Comprehensive transthoracic echocardiography (TTE) consists of a combination of two-dimensional (2D), M-mode, and Doppler imaging, with three-dimensional…