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Echocardiography and Echocardiography and IAH/ACSIAH/ACS
Jan Poelaert, MD, PhDJan Poelaert, MD, PhDGhent University HospitalGhent University Hospital
Gent, BelgiumGent, Belgium
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Echocardiography and IAH/ACSEchocardiography and IAH/ACSGlobal and Regional LV FunctionGlobal and Regional LV Function
Echocardiography and IAH/ACSEchocardiography and IAH/ACSImportance of Echo-Doppler in ICUImportance of Echo-Doppler in ICU
• TOE versus TTETOE versus TTE Acute perioperative HD instability
Ventilated patients : prone, chest drains, dressings
Intraoperative HD monitoring
Examination of prosthetic valves
Exclusion of endocarditis
Diagnosis of aortic dissection
Cardiac tamponade (atrial compression, upper mediastinum)
HD monitoring (ischaemia, preload, afterload)
Safety and Utility of TOE in the ICUSafety and Utility of TOE in the ICU
aortic dissection; 29%
miscellaneous; 19%
emboli; 26%
complication of CAD; 10%
infective endocarditis; 8%
ventricular function; 8%
Pearson AC et al. Am Heart J 1990;119;1083
Echocardiography in the ICUEchocardiography in the ICUProblem: Unexpected FindingsProblem: Unexpected Findings
• Pericardial tamponadePericardial tamponade
• RV failureRV failure
• Severe MRSevere MR
• ThrombiThrombi
• LV outflow obstructionLV outflow obstruction
• R-L Shunt or L-R shuntR-L Shunt or L-R shunt
• EndocarditisEndocarditis
Heidenreich et al. JACC 1995;26:152
TO BE RECOGNIZED !!!
TO BE RECOGNIZED !!!
Goal-directed Therapy: Goal-directed Therapy: HypotensionHypotension
• Valvular or pericardial restraint of CO
• Ventricular failure
• Non-cardiac : hypovolaemia or low afterload
Heidenreich et al. JACC 1995;26:152
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Importance of Echo-Doppler in ICUImportance of Echo-Doppler in ICU
• TOE
Poelaert J et al. Chest 1995;107:774
Echocardiography and IAH/ACSEchocardiography and IAH/ACSPathophysiologyPathophysiology
• Increased ITP
• Reduced venous return
• Left ventricular systolic dysfunction
• Right ventricular systolic dysfunction
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Diagnostic Tool Diagnostic Tool Monitoring Tool Monitoring Tool
• Systolic function: LV and RV
• Preload
• Fluid responsiveness
• Afterload
Haemodynamic MonitoringHaemodynamic MonitoringDetermination of PreloadDetermination of Preload
Preload = ED sarcomere length
LV complianceLV compliance LVEDPLVEDP
• coronary perfusion pressure
• intrapleural pressure
• pericardial constraint
• interventricular dependence
each dimensional parameter ~ preload each dimensional parameter ~ preload
Haemodynamic MonitoringHaemodynamic Monitoring
Haemodynamic MonitoringHaemodynamic MonitoringEstimation of Stroke VolumeEstimation of Stroke Volume
Echocardiography and ACSEchocardiography and ACSFluid ResponsivenessFluid Responsiveness
Right Heart FailureRight Heart Failure
• IHDIHD
• Pressure overloadPressure overload
• Volume overloadVolume overload
Echocardiography and ACSEchocardiography and ACS Right Heart Failure: Pressure OverloadRight Heart Failure: Pressure Overload
• Instantaneous Instantaneous diagnosisdiagnosis
• PreloadPreload
Echocardiography and ACSEchocardiography and ACS Right Heart Failure: Pressure OverloadRight Heart Failure: Pressure Overload
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
Echocardiography and IAH/ACSEchocardiography and IAH/ACS
RVSP = 4V² + CVP
Normal Left Normal Left VentricleVentricle Hyperdynamic Left VentricleHyperdynamic Left VentricleDecreased Left VentricleDecreased Left Ventricle function function
functionfunction
SepsisSepsis HypovolemiaHypovolemiaInotropes?Inotropes?
Preload Fluid Preload Fluid responsiveneresponsivene
ssss
SPVSPV
∆∆VVaoao
LVEDAILVEDAI
LV systolic function LV systolic function
ContractilityContractility
load dependentload dependent load load independentindependent
LVFACLVFAC (dP/dtmax)/EDV(dP/dtmax)/EDV
S (TDI)S (TDI)
dP/dt maxdP/dt max
AfterloadAfterload
Ea = Ea =
SVRI = SVRI =
ESMWS = 1.33 x SBP xESMWS = 1.33 x SBP x
SV
PP
CI
CUDMAP 80
Am
Ac
After the initial therapy, guided by echo parameters,
there is time to install more continuous monitoring.
Modified from Poelaert et al. Chest 2005
Christmas’ Echo 2007Christmas’ Echo 2007: 21-22 dec 07: 21-22 dec 07
88thth Int. Perioperative Int. Perioperative Echocardiography Course (IPEC)Echocardiography Course (IPEC)
With preparation of the Examination for the
With preparation of the Examination for the
European Accreditation on Echocardiography
European Accreditation on Echocardiography
We must have the We must have the courage to examine courage to examine everything,everything,
to discuss everything,to discuss everything,
and even to teach and even to teach everythingeverything
CondorcetCondorcet
Transoesophageal Echocardiography in Transoesophageal Echocardiography in Anaesthesia and Intensive Care MedicineAnaesthesia and Intensive Care Medicine
22ndnd Edition 2004 – Ed. J Poelaert – K Skarvan - Edition 2004 – Ed. J Poelaert – K Skarvan - BlackwellBlackwell