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Echocardiography in Infective Endocarditis

Introduction Infective endocarditis (IE) is a serious infection of the heart that, despite advances in diagnosis and treatment, is associated with in-hospital and 1-year mortalities of approximately 20% and 40%, respectively. IE is also associated with major morbidity with embolic events (stroke in 17% of patients, non-neurologic embolus in 23%), heart failure (32%), abscess (14%), and the need for surgery (48%) being relatively common events. With…

Other Cardiac Masses

Introduction Among cardiac masses, the three most common types are tumors, thrombi, and vegetation. However, there are a variety of other structures that can be misinterpreted as cardiac tumors. These include normal anatomic structures or variants of the heart, abnormal structures, and echo artifacts. With the abundance of echocardiograms being performed today, it is inevitable that variants of normal structure, echo artifacts, degenerative or acquired lesions,…

Identification of Intracardiac Thrombus

Introduction Intracardiac thrombi represent a subset of cardiac sources of embolism, are common in a variety of cardiac disease states, and account for 15%–20% of the 500,000 annual strokes in the United States. In addition, they are important sources of systemic emboli to other vascular beds. Thrombi may exist in all cardiac chambers and can either originate from an extracardiac source with migration to the heart…

Primary and Secondary Tumors

Introduction The first demonstration of a left atrial myxoma by ultrasound occurred in Germany in 1959. Since then echocardiography has evolved to become the usual initial modality for detecting a cardiac tumor. Cardiac neoplasms are found in only 1%–2% of cases in general autopsy series. For this reason, routine screening to rule out cancer in the heart is not appropriate and would undoubtedly lead to many…

Pulmonary Hypertension

Introduction The echocardiographic assessment of pulmonary hypertension (PH) must include an appreciation of the interaction between the load imposed on the ventricle by the increased resistance of the pulmonary arteries and the contractile force of the right ventricle (RV). It is a combination of these two factors that determines the right ventricular and pulmonary artery pressures ( Fig. 36.1 ). Thus, the first principle is that…

Pulmonary Embolism

Introduction Pulmonary embolism (PE) is associated with substantial morbidity and mortality, accounting for over 50,000 deaths per year in the United States. PE coexists with other cardiac and pulmonary diseases and remains a diagnosis that continues to elude clinicians. Indeed, PE has been called “the great masquerader” because the signs and symptoms of PE mimic that of other diseases. The emergence of interventional strategies that remove…

Diseases of the Aorta

Introduction An evaluation of the aorta is a routine part of the standard echocardiographic examination. Indeed, aortic pathology is often first discovered on an echocardiogram that was ordered for other indications. Anatomy, Nomenclature, and Dimensions The thoracic aorta is divided into four segments ( Fig. 34.1 ), both because of anatomical distinctions and because they are affected differentially by conditions that affect the aorta. The aortic…

Pericardial Disease

Introduction The pericardium is a thin-walled structure composed of two layers, a serous visceral layer (epicardium) and a fibrous parietal layer, both of which surround and protect the heart. Between these layers, up to 50 mL of pericardial fluid normally cushion the heart while the pericardium serves as a barrier to inflammation and infection. Limited epidemiologic data are available for the incidence and prevalence of pericardial…

Echocardiography in Percutaneous Valvular Intervention

Introduction Since the development and implantation of the first transcatheter pulmonic and aortic valves, there has been a rapid acceptance of transcatheter valve implantation as a solution to high-risk or inoperable patients with severe, symptomatic valve disease. Randomized trials have since supported the use of transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis in these patient populations with evidence of efficacy and safety in…

Prosthetic Valves

Introduction Echocardiography is an essential tool in the evaluation and management of patients with prosthetic valves. Its use requires an understanding of valve design, normal prosthetic appearance and function, imaging artifacts introduced by valve elements, and the spectrum of valve dysfunction. This chapter will cover these topics with a focus on aortic and mitral prostheses since these are the most commonly implanted valves and those for…

Tricuspid and Pulmonic Valve Disease

Introduction Echocardiography plays a unique role in the assessment of the tricuspid and pulmonic valves. However, their evaluation is often suboptimal because typical imaging protocols may overlook the views that best display pulmonic and tricuspid anatomy and function. Recent advances in percutaneous valve procedures for pulmonic and tricuspid disease have created a demand for detailed images and precise echocardiographic measurements of both the tricuspid and pulmonic…

Aortic Valve Disease

Introduction Aortic valve (AV) disease is the most common valve disease in developed countries. Aortic stenosis (AS), which is most often due to calcification and degeneration of congenitally normal tricuspid valves, affects approximately 1.5 million people in the United States with a prevalence that increases with age. While hemodynamically significant AS (moderate or severe) is unusual before the age of 65, in those aged 65–74 the…

Mitral Valve Disease

Introduction Approximately 2.5% of the general US population suffers from significant valvular heart disease. Mitral valve disease (MVD) constitutes one of the most prevalent forms and is associated with significant cardiovascular morbidity and mortality. Furthermore, the prevalence of MVD increases exponentially with age reaching up to 10% in patients older than 75 years. Typically, MVD can be classified into mitral regurgitation (MR) and mitral stenosis (MS),…

Stress Echocardiography and Echo in Cardiopulmonary Testing

Introduction Ischemic Cascade Myocardial ischemia is classically characterized by a consistent, time-sequenced series of events known as the “ischemic cascade” ( Fig. 27.1 ), which form the physiologic basis for greater sensitivity of stress testing with imaging (including echocardiography) compared to electrocardiography alone. The imbalance between oxygen demand and supply driven by heterogeneity in coronary flow initially results in metabolic changes, followed by abnormal mechanical function,…

Echocardiography in Assessment of Ventricular Assist Devices

Introduction Mechanical circulatory support is increasing in the acute and chronic management of heart failure patients. Both short-term and longer-term support ventricular assist devices (VADs) are in clinical use. Echocardiography may help guide patient selection as well as placement, optimization, and surveillance of these devices. This chapter will focus on the role of echocardiography in the evaluation and management of the patient who may need or…

Echocardiography in Assessment of Cardiac Synchrony

Introduction Electromechanical association in a normal heart results in synchronous regional left ventricular (LV) contraction. Differences in the timing of regional contraction may be associated with the failing human heart. Interest in echocardiographic assessment of synchrony began with applications for pacing therapy, in particular cardiac resynchronization therapy (CRT). CRT, also known as biventricular pacing, was an important advance in treatment of heart failure (HF) patients with…

Restrictive and Infiltrative Cardiomyopathies

Introduction Restrictive cardiomyopathy (RCM) refers to either an idiopathic or a systemic myocardial disorder in the absence of underlying atherosclerotic coronary artery disease, valvular disease, congenital heart disease, or systemic hypertension, which is characterized by abnormal left ventricular filling, and is associated with normal or reduced left ventricle (LV) and right ventricle (RV) volumes and function. The term is not precise, but it incorporates infiltrative and…

Hypertrophic Cardiomyopathy

Introduction Hypertrophic cardiomyopathy (HCM) is characterized by unexplained myocardial hypertrophy, that is, hypertrophy that has developed in the absence of other attributable etiology, myocyte disarray, and myocardial fibrosis ( Fig. 23.1 ). In large part, through cardiac imaging and molecular research, our understanding of the pathophysiology, epidemiology, and prognosis of HCM in the last several decades has rapidly advanced. Echocardiography is an essential tool for examining…

Dilated Cardiomyopathies

Introduction Dilated cardiomyopathy (DCM) is predominantly diagnosed according to echocardiographic features that include left ventricular or biventricular dilation and reduced systolic function. Current classification schemes from major heart societies exclude primary ischemic heart disease or abnormal loading conditions (such as hypertension or valvular disease) that may cause a similar impairment in global systolic function. Clinically, the term ischemic cardiomyopathy is frequently used to refer to the…

Echocardiography in Heart Failure

Heart failure (HF) is a clinical syndrome characterized by fatigue, breathlessness, and edema caused by an abnormality of heart function. While the etiologies of HF differ, and HF can occur with reduced or preserved ejection fraction, or with low or high cardiac output, all forms of HF share a basic pathophysiology: the inability to provide adequate cardiac perfusion to the body at rest or with exertion…