By La Cara Salma (Own work Nel vero senso della parola! (sic!)) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

A 70 year old lady was trapped for 90 minutes in her car after a motor vehicle accident in which she sustained a fractured tibial plateau…A seat belt mark was present and she developed hypotension after extrication and transfer to hospital which failed to respond to fluid loading.

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What is the normal value of this measurement?

The normal value for tricuspid annular plane excursion (TAPSE) is ≥1.6cm – but it is important to not rely on a single measurement when assessing RV function.

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What is the technique? Is the measured value normal or abnormal?[showhide]We’re measuring the RV S’ with Tissue Doppler. This is the peak systolic velocity of the lateral tricuspid annulus. S’ < 10 indicates abnormal function, so this seems normal.

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So, normal or abnormal function?

The global right ventricular systolic function is normal visually – emphasising the importance of not just relying on the TAPSE. RV function is an important assessment after trauma involving the chest, along with regional LV function and examination of the tricuspid valve which can occasionally develop severe TR.

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What is the function of the left ventricle?

Global LV systolic function is severely decreased. Hypokinesis is seen at midpapillary and apical levels. This is well demonstrated in the zoomed apical 4 chamber images below:

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What associated abnormality would be closely examined for in these views?

Apical clot, which may necessitate anticoagulation, although that would be a risk-benefit assessment in the context of trauma as in this case.

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What is this view, and how was it obtained?

Apical 2 chamber view. It has been obtained with a 3D probe and digital rotation from the 4 chamber view (note the symbol in the top left showing that 310 degrees of rotation has been used).

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What is this method of measuring LV ejection fraction called?

Simpson’s method. Where it is done in two planes (apical 2 chamber and apical 4 chamber, as here) it is referred to as a Simpson’s biplane. One difficulty with using this method in critically ill patients is the difficulty in obtaining a true apical view. These are often obtained in echo labs with patients able to lie on their side over a cutout in the examination couch, obviously impractical in ICU.

What is the differential diagnosis of the echo abnormalities found?

The main differentials are coronary ischaemia or infarct, or, particularly in light of the apical predominance of hypo / akinesia, tako tsubo cardiomyopathy. An angiogram was performed revealing no coronary disease and confirming the suspicion of tako tsubo. Occasionally, the opposite pattern (apical sparing but basal involvement) can be seen, as in the following loop:

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This was seen in the context of amphetamine use.

Cover image: By La Cara Salma (Own work Nel vero senso della parola! (sic!))

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