Transcript

Hi, I am Dr. Jason Cox.

I'm, uh, here tonight joining you with

two esteemed colleagues that are gonna talk about some

echocardiography findings, uh, specifically

with endocarditis.

Um, I'm the programmer of the Institute

for Advanced Medical Education,

and I'd like to welcome you

to our educational program this evening.

Um, IME has been educating physicians

and sonographers for 30 years.

We offer memberships that include, uh, unlimited access

to online courses, webinars, and other educational events.

Uh, for our members, we are a membership based program.

And, um, as part of being a member, there's additional, uh,

benefits including, uh, transferring credits straight

to A-R-D-M-S or CCI or A-C-C-M-E,

and, um, other, other promotional, um, uh, products that,

that we may offer.

Um, our membership options include, uh, annual membership,

uh, a one year plus the next year membership,

12 year memberships

and lifetime memberships that we just started doing.

We also offer group memberships for, uh, people that have 10

or more, uh, users

that, um, they would like to use with their, uh, employer

or, uh, any other educational system

that we also do have a lot of people that we work with.

Um, stay to the end of the program

and then we will have a special offer

for everybody that made it to the end.

Um, IME.

You can get your education anywhere, anytime, and always.

Now we're gonna talk about some, um, housekeeping items.

Uh, the first thing we're gonna do is, uh, talk about,

uh, how the program's gonna work.

So the program, which I can't actually see right now, um,

because it's too small, but the way it's gonna work is we're

gonna have, uh, Billy Cathy, who's an expert, uh,

cardiac sonographer, and the president

of the Midwest Cardiac Sonographer Society,

and his, uh, partner Ed star,

who's also an expert cardiac sonographer and vice president

and foreign president of the Midwest Cardiac Society.

Uh, talk tonight about, um, endocarditis.

Um, uh, Billy's gonna present a,

a lecture on this topic at the midway point.

We will have some time for questions,

and we do encourage you guys to post your questions in the,

uh, comment area, and then we'll be able to see those

and then we can discuss them.

Um, more questions, the better.

So, um, let's go back

and we're gonna talk about our, uh, disclosures.

So the Institute for Advanced Medical Education is, uh,

credited by the A-C-C-M-E

to provide continuing medical education for physicians

and training for non-physicians.

This activity has been planned

and implemented in accordance

with the accreditation requirements

and policies of the accreditation Council

for continuing medical education.

IME designates this live online webinar for a maximum

of one A-M-A-P-R-A category one credits.

And physicians and attendees should only claim the credit

commensurate to the extent

that their participation in the activity.

So if you stay for an hour, claim, one hour, if you stay

for half an hour, claim 0.5, um, in compliance

with the essentials and standards of A-C-C-M-E, the authors

of the CME activity are required

to disclose any significant financial

or other relationships that they may have

with commercial interests.

Billy, Kathy, and Ed Star and myself

and anyone else who has been involved in the planning

of this activity have no disclosures

and any identified relevant conflicts of interest

that may have come up have been mitigated.

Um, now that we have that over with, we can move on to, uh,

some introductions of our, um, esteemed lecturers today.

Um, ed Star, I've worked with him for several years.

Um, he is a excellent sonographer

and echocardiographer that works with me

through various different clinics that I've staffed.

Um, he's, uh, co-owner of, uh, his own ultrasound clinic

where he does cardiography, echocardiography,

and vascular ultrasound in general,

and musculoskeletal ultrasounds.

And he, like we have already said,

has been he's current vice president

of the Midwest Cardiac Sonographer

Society and former president.

Um, I think I'll let Ed's, um, introduce Billy,

who he knows better than I do,

but I've been working with Billy

for a little bit too. Ed. Great.

Great. Uh, I'd like to introduce, uh, Billy, uh,

had the pleasure

and a great opportunity to work with Billy over the years,

uh, with our local, uh,

Midwest Cardiac Sonographer Society, uh, here in St.

Louis. It's been a very active society for a very long time,

and it's just been a great pleasure to have, uh, uh, someone

as esteemed as, as Billy as, uh, heading and,

and president, current President, uh, presently,

he's the top resource sonographer at Barnes

Jewish Hospital in St.

Louis. And Barnes Jewish is considered one

of the top hospitals in the nation.

Uh, so it's really a privilege that he gets to work in a,

in a very large, uh, teaching institution.

Uh, he is a superb

and expert cardiac sonographer, um, currently the, uh,

MCSS President for many years.

Um, and he's lectured to our, uh,

society group on multiple occasions, and we host symposiums,

and he's, uh,

provided lectures almost every time we have a symposium.

I also consider him a, uh, social influencer

because, uh, he, in, in, in the best sense

of the word, uh, puts out content that is really

teaching related, excellent quality, uh,

on various platforms.

And so, uh, uh,

whatever you think about social influencers, he's the great one.

So anyway, uh, I would like to, uh, introduce, uh,

Billy at this time, and he is going to, uh, speak with us,

uh, on endocarditis unveiled beyond vegetations

and avoiding critical mistakes.

So at this time, I'll turn it over to, uh, Billy

and, uh, to start the presentation.

Thank you so much.

Thank you, Jason. And, uh, thank you, ed.

I'm very happy to, uh, have this opportunity to talk about

endocarditis tonight.

Uh, I'd like to welcome everyone.

Uh, some of you may have seen some of my postings.

Uh, as you probably can tell, I really enjoy my job.

I like what I do, and, uh, I, uh,

really enjoy making an impact on a patient's lives.

Uh, people in, in this field.

You know, if you, if you are a sonographer,

whether it's cardiac, vascular, whatever you do, uh,

with ultrasound, it is definitely a highly

skilled profession.

Not anyone can do this job.

And I hope you feel, uh, appreciated,

and I hope you are aware of your skills

and, uh, understand that, you know, without you,

doctors wouldn't be able to make the decisions

that they need to make, and patients wouldn't be able

to get the, uh, treatment that they need to get.

So, hats off to all the sonographers, uh, out there tonight.

Okay. A topic tonight is Endocarditis Beyond Vegetations.

And, uh, I chose that title

because, uh, oftentimes the first thing

that we think about when we think of about, uh,

endocarditis is vegetations.

And it's not just vegetations. Okay?

There are other things that go on along with, uh,

a person having, uh, endocarditis besides, uh, vegetations.

So, endocarditis is a left, uh, excuse me,

a life threatening, uh, inflammation of the lining

of the heart valves and chambers of your heart.

Uh, oftentimes we don't, may not think

of it being life-threatening,

but it is definitely a, a life-threatening disease.

Next slide, please.

And, uh, some of the causes of infective endocarditis.

Uh, basically, you know, whenever germs, bacteria,

or fungi enter the blood

and travel to your heart, it can, uh, cause an infection.

And some of the ways that this can happen is, uh,

through improper dental care, uh,

catheters, IV drug use.

All of these things, uh, play a role in person, uh,

developing, uh, endocarditis.

Next slide, please.

Also, um, the signs

and symptoms of infectious, uh, endocarditis.

Someone that develops a new on onsite set of, uh,

heart failure, bacteremia, fatigue, flu-like symptoms,

something like having a persistent fever

and chills, night sweats, shortness of breath,

swelling in your feet, legs, or abdomen, a new murmur.

I think the ones that are really cru crucial for, uh,

endocarditis would be the, uh,

persistent fever and a new murmur.

If you have a patient that's having that, uh, as well as,

uh, positive, uh, blood, blood cultures,

you should be highly suspicious for endocarditis.

And some of the less common signs would be unexplained

weight loss, blood in your urine, tenderness in your spleen.

Sometimes these patients also develop jane weight lesions,

which would be red spots on the soles of your, their feet

or palms of their hands.

Uh, also, uh, sometimes they'll have osler nodes

and, uh, basically that's like purple spots on their hands,

and they can develop this, uh, rash Pet K rash.

It's like a, a blister type rash.

Very red, as you can see in this picture.

It can, uh, and, uh,

also sometimes they might develop a splinter, he hemorrhage.

And these hemorrhages, they, they run in the direction

of nail and they form under the nail of your, uh, fingers.

And some of the things that you, uh,

sometimes find in the echo when you're imaging patients

who have endocarditis, uh, they'll develop, uh,

you'll see oscillating masses on a valve,

a supporting structure or on the path of regurgit jet

or a, a device.

Anytime there's a, any type of foreign, uh,

body introduced into your, uh, into the body, any a device

such as a, uh, pacemaker wire

or a catheter, that will put you in an increase of, uh,

developing endocarditis.

And, uh, when we see a vegetation

vegetations as far as their appearance, they can be linear,

round, irregular shape shaggy.

And normally there we will be attached on the atrial side

of either the mitral or tricuspid valve,

or you'll see it on the ventricular side of the aortic

or pulmonary pulmonic valve.

Uh, these patients also sometimes can develop as abscesses,

and, uh, of course, you'll see, uh, regurgitation.

Uh, you go also may see things like a perforation,

pericardial effusion, uh, destructive, uh, valve lesions.

Like, uh, someone might have a valve that used to be normal.

All of a sudden you'll see a prolapse or aneurysm.

Uh, you'll see changes in the prosthetic valve hemodynamics.

You'll get like an increased gradient across the valve.

Uh, it might become, uh, stenotic.

Um, you also may see a new

or partial dehiscence of a prosthetic valve.

The valve may actually break away from the, uh, sutures,

and it will, uh, start to bounce around in the heart.

And, uh, of course, you also see paravalvular leaks.

And here's the images of, uh,

OCI mass.

You can see how it's, uh, oscillating.

Uh, the image on the left is a vegetation

that's on the aortic valve,

and the image on the right would be one

that's on the mitral valve.

And you look closely it, it oscillates, especially the one

that's on the, uh, aortic valve.

And these patients may also sometimes develop an abscess,

which is like a pocket of infection around a valve.

More commonly, you'll see them around the aortic valve.

As you see in this example here,

you see all the heavy calcification,

and you see how it's looks enlarged.

It's filled with like a lot of pus and, and fluid.

And it's from the, uh, infection, uh, from endocarditis.

Next slide. And this is a good example

of, uh, dehiscence.

If you look closely at this, uh, patient's, uh,

prosthetic aortic valve, you see how it's rocking.

That valve shouldn't rock.

It should be secure in place as the heartbeats.

But since this, and it's also very thick,

the leaflets are very thick with, uh, endocarditis.

So the, uh, endocarditis has kind of eaten away at the, uh,

at the, uh, the sutures

and as well as the, the, the tissue around the valve

and causing it to bounce around like that.

Next slide, please. And here's an example of, uh,

tricuspid regurgitation.

Next slide. So we'll start with, uh,

our first case for tonight.

So the first case is from a, uh, 29-year-old female

who has a history of, uh, IV drug use.

She's been using heroin, cocaine, fentanyl, amphetamines.

Uh, she was admitted for management of multifocal pneumonia,

UTI and bacterial endocarditis.

And she initially complained of shortness of breath with,

uh, supra pubic pain.

Her white blood cell count was elevated,

and she had a blowing systolic murmur,

which was heard on a physical exam.

Her chest x-ray also showed a bilateral lobe, lower lobe,

and right middle lobe, uh, consolidations, which would, uh,

which could be multifocal pneumonia given her fever,

IV drug history, murmur on exam, and chest x-ray.

There was a concern for bacterial, uh, endocarditis

that was throwing septic emboli.

Next slide, please. And here's, uh,

the first image of her echo.

This is the per sternal lung axis.

In this view, we're seeing the, uh, left ventricle,

the mitral valve, the aortic valve, as well

as the right ventricle.

Really don't see anything abnormal here.

The only thing I would say would, will be an abnormal,

would probably be the size of her right ventricle.

It does appear to be enlarged. Next slide, please.

And, uh, we're quickly, we're gonna talk about imaging, the,

uh, tricuspid valve.

So we're gonna talk about the RVIT view

or the right ventricular inflow view.

When you angle down to, uh, bring in this view,

it's important to understand the anatomy.

And, uh, from the diagram here, uh, depending on

how your angled you'll, you'll see different parts

of the tricuspid valve.

Okay? Uh, if you look at the, uh, image on the left side

of the screen, image a, it is showing the, the blue leaflet,

which will be the anterior leaflet,

and then the yellow, uh, leaflet, that,

that is the septal leaflet.

And you know, it's the septal leaflet

because you, you're seeing the, uh, coronary sinus as well

as the, uh, ventricular septum, okay?

And if you, uh, tilt more posteriorly,

you will tilt away from the septal leaflet

and you'll bring in the, uh, posterior leaflet.

So it can be tricky sometimes, uh, knowing

what leaflets you're seeing in this view, uh,

with the tricuspid valve bean

that we only seeing two leaflets at the same time.

That's why I think 3D imaging, uh,

is very helpful when you're trying to, uh,

analyze the, uh, tricuspid valve.

'cause it allows you to look at all three leaflets

simultaneously and from various angles

to really assess what's going on with the valve.

Next slide, please.

So this is, uh, her, uh,

tricuspid valve looking from the RVIT view.

I have it labeled for you.

The, the anatomy, the anterior leaflet is at the top

of the screen, and her septal leaflet

is there at the bottom.

It looks very small.

Um, don't really see any abnormal ab anything abnormal about

the her leaflets, uh, don't see any, uh, any thickness

or any, uh, echo densities.

So let's go to the next slide, please, and we zoom up

whenever you're, uh, assessing a patient for endocarditis.

I think high res zoom is very important.

Uh, yeah, utilizes to zoom to try

and get as clear a look, uh, as, uh, of the valve

as possible, because especially in the early stages

of endocarditis, uh, you know,

the vegetations can be very small,

and you might miss 'em if you don't look careful enough.

And, uh, early detection is critical, uh, when dealing with,

uh, patients with endocarditis,

because you don't want to wait until it's too late.

If it advances to, to a certain point,

then it makes it much harder

to treat these patients when it's,

when they're in the early stages, the, uh,

antibiotics can work better

and, uh, resolve this issue as opposed to the late stages

of, uh, endocarditis.

Next slide, please.

Now, as I, uh,

whenever I do a echo, I try to utilize all

of the tools on the machine.

Uh, and all of our machines have 3D capability.

I don't know where you are working, uh,

if your machines have 3D.

So if you're able to do 3D uh, on your machines,

it allows you to do biplane imaging, which I think is very,

very helpful when analyzing different structures

of the heart, allows you to see two planes simultaneously.

And sometimes it can be very helpful when you're trying

to identify structures, like if, if something's ACE leaflet

or anterior leaflet.

If you do a biplane image

and you put your, uh, cursor on that structure, you,

you can see the orthogonal view simultaneously,

and it can give, it can be very helpful in trying

to identify, uh, what you're looking at.

So I utilize biplane here

to look at the tricuspid valve in both the RVIT view as well

as the short axis view.

And I, I'm still not seeing any type of, uh, vegetation

or anything abnormal, uh, on the valve.

Next slide, please. Now,

when we add color, we start to see

that there is some significant regurgitation here.

I believe we're seeing the, uh, anterior and septal leaflet.

Uh, we're seeing a lot of turbulence, uh,

there, the color there.

Uh, but I'm not sure if, if, if it's originating from the,

uh, septal leaflet

or if it's coming from somewhere else, like the, uh,

posterior leaflet, which is not in plain,

it's kind of out of, out of plain.

So we're not really seeing, you know, where the, uh,

flow convergence is.

We're seeing the color, but we're not quite sure

where it's coming from.

Next slide, please. Now, I'll go to the, uh, short axis.

Again, I'm angling down towards the LVLT to try to bring in,

you know, more of the leaflets.

And, uh, going from left to right, we can kind

of see the poster that, where, that's

where the posterior leaflet would be.

You're not seeing it very clearly.

And then you'll see the, uh, anterior leaflet,

which is the longest leaflet,

and then that very short, uh, leaflet

that you see on the right side of the screen,

that will be the septal leaflet.

And still, we're not seeing any vegetations.

We're seeing, uh, regurgitation, but no, no vegetation.

Next slide, please.

Now, I'm doing a, a color compare, uh,

where you can see the color, the, uh, tricuspid valve with

and without color at the same time.

And now we're getting a better understanding of

where this jet is originating from.

It's coming from where we see, where we're seeing the, uh,

posterior leaflet.

It's a very eccentric jet, actually hugging the, uh,

anterior leaflet as well as the, uh, inter atrial septum.

So very eccentric, uh, jet of, uh,

tricuspid regurgitation coming, uh,

possibly from the posterior leaflet of the tricuspid valve.

Next slide. So this is the, uh, per sternal short axis

of the left ventricle, uh, has normal LV function.

But if you look closely, there is some slight

septal flattening, uh, sep, a diastolic, uh,

septal flattening that you're, uh, seeing.

Uh, go to the next slide, please.

And this is the apical four chamber.

Seeing all four chambers of the heart, uh, just like I was,

I noticed from the per sternal lung axis view,

the right side of the heart is enlarged.

Uh, normal right ventricle should not be the same size

or larger than the left ventricle.

Uh, from this view, her right ventricle appears to be larger

than her left ventricle, which is abnormal.

The, uh, right atrium appears large as well.

And if you look at the, uh, inter atrial septum, you notice

how it's bowing to the right during systole,

which would coincide with that eccentric jet

of regurgitation, because it's hitting that septum,

causing it to, uh, bow to the right there

or to the left, really to the left of the heart.

And here's a RV focus view here.

I'm trying to see if I can, uh, see

that posterior leaflet a little better.

This is another challenging view to,

I sometimes can be challenge to challenging

to identify which leaflet that you're seeing.

Uh, the only leaflet that you know for sure

in this view is the septal leaflet, which is attached

to the septum there, you know,

that's the sep septal leaflet,

but sometimes it can be the, uh, anterior leaflet as well

as the posterior leaflet.

So you have to be, you know, there are signs

that you can see if you, if you start

to see the coronary sinus, uh, in this view,

then you're seeing the, uh, posterior leaflet.

Uh, we're kind, you can kind of see it a little bit, uh,

near the, uh, interatrial septum

and kind of bring, if I were to tilt a little bit more,

we're bringing the coronary sinus.

And if you angle more anteriorly, you'll bring in the,

uh, anterior leaflet.

So from this view, the posterior leaflet,

it does look a little abnormal to, to me,

I don't see any vegetation.

If we go to the, uh, next slide please.

I believe I'll zoom up a little closer.

Uh, well, first we'll put color,

and that's, we're, we're seeing the flow conversions.

You see that nice little dome there of color, uh,

that just lets you know that's where the, uh,

regurgitation is originating from.

Okay, we, we, this is the best view

that we've seen it from so far.

We kind of saw it in the other views,

but we see it best here.

So that's why it's important for us to look at, you know,

structures, uh,

and different views from various views from various angles

to really get a good idea of, uh, what's going on.

And this is a good example of that. Next slide, please.

Now, here's a zoomed up image of the, uh,

tricuspid valve looking at the, uh, posterior leaflet.

And if you look closely, uh, it appears to be prolapsing.

Uh, and, and actually in areas like

you can't really see if it's coapting with the,

uh, septal leaflet at all.

There's kind of like a little drop out there

where those two leaflets should be touching.

It's kind of hard to say

for sure if they're actually touching.

Uh, um, but so that, that does look, uh, abnormal.

But still, no, no vegetation.

Okay, we haven't seen, uh, uh, any, uh, vegetation.

Next slide, please. And then we'll do a color compare again,

just to be thorough and to really demonstrate to the reader,

you know, you know what's going on.

So they can see that, you know, it's coming from the, uh,

posterior leaflet.

And you can go to the next slide, please.

Uh, looking from subcostal, uh, you know, these are all,

all the views that you can see.

The tricuspid valve, we look from the, the RVIT view,

the short axis view, your apical four chamber.

You also wanna look sub costly as well.

Like, like I said, it's important to look, uh,

image from all views.

Don't take any view, uh, for granted,

because that one view that you don't look may be, uh,

the one that makes the, uh, diagnosis.

Next slide, please. And if we add colors,

it's pretty much showing us the same thing that

very eccentrics yet of, uh,

tricuspid regurgitation going towards the, uh,

interatrial septum.

Next slide. So, like I said, you know,

when I do echo, I like to use all the twos.

I'm very, I'm a very big fan of 3D imaging.

Uh, to me, it, man, it just really, when I started learning

how to do 3D, it was just like learning echo all over again.

It was just like something new and fancy.

And I, it's a very powerful tool.

And, uh, these 3D images are gonna give us a clear, uh,

demonstration of what's really going on with this patient.

Uh, an important note about this echo

as I was doing this echo, uh, being that this patient's

with her history of IV drug use, uh, some

of you may have experienced this,

sometimes these patients can be very unpredictable.

Uh, they can have mood swings,

they can go from one extreme to another.

And I was very fortunate, uh, to, uh,

when I was pretty much almost done with the echo,

she was just like, she just jumped up and said, that's it.

I'm done. Stop. So she wouldn't let me do any more imaging,

and I was glad I grabbed those 3D images that I'm about

to sh to show you.

And one of the good things about 3D images is

that you can do so much post-processing, okay?

All you have to do is capture a good quality data set,

and the patient doesn't even have to be there.

And you can go through there and just examine it

and analyze it from all different angles, and,

and you can get views that you can't even get by your hand,

with your hand, you know, during the normal, uh,

transthoracic echo.

So let's go to the next slide, please.

Okay, so this is an image of the tricuspid valve.

So, uh, I don't know if, how many of you are familiar

with a 3D image of the tricuspid valve?

So I have it labeled nicely there for you.

So I have all the anatomy LA labeled, uh, we're looking from

the, looking at the valve from the, uh, ventricular side.

So whenever you're looking at the tricuspid valve from the

right vent ventricular side, uh,

whenever you see the septum, which, uh, which is

that kinda round arch that you see on the right side

of the screen when you identify the septum,

that's why I always try to identify the septum.

And then identifying all the anatomy is just very simple.

So the, whenever you see the, wherever you see the septum,

you'll and you, the leaflet that you see that's right next

to the septum, that is the septal leaflet.

That's where I put the s for, for septal leaflet.

Then above that would be the anterior leaflet,

and then below that,

or across from the septal leaflet, that's

where your posterior leaflet should be.

Now, if you look at this image, you don't really see much

of a posterior leaflet.

You, you do see, however, a lot of dropout, which again,

explains the, uh, why we were seeing, you know, that we,

we had determined that's where the, uh,

tricuspid regurgitation was coming from.

And now we, we kind of see why.

Go to the, uh, next slide, please.

Uh, another tool that I like to use

with the 3D is the flexi slice.

And flexi slice allows you to go into the 3D dataset.

And like I said, you can look at it from multiple views,

you can chop it up, dice it,

however you want to really ana, analyze, uh,

the different structures of the heart.

You can also do measurements, uh,

and like I said, all of this can be done post-processing.

These, all these images I'm showing you.

Now, were done, you know, after I was done with the echo

and the patient was gone.

So I have it labeled for you once again.

And then in, if you look at the,

in the upper left hand corner, uh, you can see that little

area, uh, on the 3D image that, where it's, it's labeled P

for posterior leaflet.

We're not seeing much of a posterior leaflet there.

Uh, we see the anterior in septal leaflet.

And if you look to the right of the screen, this kind

of gives us a better apical four chamber view, per se.

Here you can see the, uh, septal leaflet

and the posterior leaflet,

and you can see where there's kind of like a prolapse.

And, you know, there's a little drop out there where the,

those two leaflets should be coming together.

They're not quite coming together.

And, uh, we can go to the next slide, please.

Now we're gonna flip that, uh, 3D image around

and look at it from the atrial side.

So now the septal leaflet is gonna be at the left

of the screen where you see the s anterior

leaflet still at the top.

And then where the p is, is where your posterior leaflet is.

And if you look carefully, uh, when the valve closes,

you'll see this little bump or protrusion.

It looks almost like a, a, uh, prolapse or flail segment.

Uh, you can clearly see there's a abnormality there.

And the area of the posterior leaflet, which is kind

of consistent with what we, which, with

what we've been seeing, uh, so far

with all the other images.

Next slide, please. I also like

to utilize flexi light.

Flexi light allows you to, uh, put light on structures

and it casts like shadows.

And if you, you know, angle

and manipulate it, you can really be, uh,

bring out the fine details, uh, of the anatomy,

and it can allow you to see things much better.

And here it's just a, allows me, I think I can see

that area of concern.

That's, uh, an the pro where the, uh,

posterior leaflet there, that's, there's a, uh,

defect there that we're seeing.

Go to the next slide. And if we add color,

uh, we can again, clearly see

that there's a jet coming from the posterior leaflet.

It's hitting the anterior leaflet, then the septal, the, uh,

inner atrial septum, just like we saw in all the views.

So this kinda like gives you everything in one picture.

That's one of the things I like about 3D.

It allows you to see everything.

It gives you a complete picture.

So when we do our 2D imaging, you know,

we're looking at a 3D three dimensional structure through,

you know, 2D images,

and you don't really appreciate, you know, everything

that's going on with the structures and the anatomy.

And it, uh, to me, nothing beats, uh, 3D imaging.

Next slide, please. So you can also,

like I said this, again, this is an image

with a color dataset that I acquired using the, uh,

flexi flexi slice.

And by doing this, it allows me to quantify

the regurgitation, and we can quantify the regurgitation

by measuring the, being a contract.

Okay? So that's one thing about tricuspid regurgitation.

It can be very difficult to, uh, quantify,

uh, for various reasons.

Uh, one of the common ways that we quantify, uh,

regurgitation, especially with, uh, mitral regurgitation,

we like to utilize pisa.

And it's not really the best thing to do with, uh,

on the tricuspid valve,

because oftentimes the jets, excuse me, the,

the jets aren't, uh, round or hemispheric.

They're more of a oval shape.

So PISA really wouldn't give you a accurate assessment.

Uh, but when you can actually puller the vena contractor,

uh, as you can do with, uh, the 3D uh, here,

it gives you a better assessment, in my opinion.

Go to the next slide. And that's what I did

with this patient, and I was able

to get the avena contractor of 0.6 centimeters square.

So, again, I, I can't overemphasize, uh,

how much 3D can, uh, add to your,

your studies if you're not doing it.

Uh, I recommend that you, that you do.

Uh, and, um, a lot of the things that I do, you know, uh,

it's not necess someone is not

necessarily teaching me these things.

3D 3D imaging is a lot like any other types of, uh,

ultrasound imaging.

Uh, in order to learn it, you have to do it.

Uh, if you're not doing it, you're,

you're never gonna learn to do it.

And I, I just try to do it on every patient.

I don't wait for special cases.

I look at, I, you know, and I look at, I go in

and I look at, uh, cases that I've done previously,

and I look at the data sets, and I, I, I analyze them.

I, you know, slice and dice 'em, I crop 'em.

And all of these things will build your skills up the

more you utilize it.

And then when you do have a special case like this,

then you can go all in.

You can be confident, uh, with the skills

that you have developed by putting your, uh,

3D imaging into practice.

So don't wait. Uh, some people say, well, I'm just waiting

for a patient with, uh, the best images,

or I'm waiting for a special case.

And sometimes I talk to these people

and they're still waiting, you know, don't wait.

Just, you know, every time that you image a patient,

regardless of the image quality

or whatever, try to use, uh, 3D to build up your skills.

It'll make a big difference. Next slide, please.

And here's some more views of the tricuspid valve.

This 3D image was taken from the, uh, uh,

apical four chamber,

and you can really see nicely that, uh, flow conversions,

uh, where the, uh, TR is coming from.

And next slide, please.

And there, this is me again, just taking a,

that another 3D data set, cropping it,

and really focusing on, on the, uh, on that area.

And you can see very nicely, this is probably the best shot

that I got from the whole study.

You can see that there is a, like, nice little round

perforated area of the leaflet of the valve here,

and it's just like a nice little circle there.

And that's where that regurgitation, uh, is coming from.

So even though this patient didn't have a vegetation per se,

you can, we can pretty still be pretty confident

and pretty sure that her tricuspid valve was damaged

from endocarditis.

The endocarditis, she probably had a vegetation,

more likely had a, a vegetation.

And this on her posterior leaflet that, uh, ate, ate,

ate away at the valve.

And, uh, and that was probably why, you know,

on their checks, chest x-ray

and some of the other tests they were seeing, uh,

emboli in her lungs coming from the, uh, vegetation

that broke off away from the tricuspid valve.

Next slide, please. And here's

another view of it as well.

Okay, next slide. Now we're gonna go to our second case.

This next case, uh, this was a 40-year-old male

with a history of both tricuspid and mitral valve.

Endocarditis also had septal emboli to the lungs,

kidney and retina.

He had MRSA bacteria. He was growing.

MRSA bacteria in his blood cultures had hepa hepatitis.

And, uh, he was first diagnosed

with tricuspid valve endocarditis in, uh, January of 2020.

He un underwent a debulking and repair, uh,

and complete his, his, uh, antibiotics in March of 2020.

So as the debulking, uh, that he went through,

I don't know if you're familiar with that.

It's a, uh, sometimes for patients, especially these, uh,

IV drug users being that, uh, most

of the time surgeons do,

do not wanna operate on these patients

because of, uh, their illness of them having, uh,

you know, drug addiction

because they, you know, the, the surgeons are reluctant

to operate

because if they're still utilizing drugs,

they're just consistently putting themselves at risk.

So if they do a repair

or replacement, uh,

all they're gonna do is come right back again

and have the same thing done again.

So they don't want to do surgery on them.

So, so they like to try to do things besides surgery.

And one of the things that they do sometimes

that they'll use what they call a endo vac,

where they actually run a catheter into the heart

and they vacuum away the, uh, vegetations off the valve.

Uh, and I think this is what this patient had.

And, uh, we can go to the next slide.

So this is this patient's, uh, peroneal lung axis view.

Uh, you know, we see a vegetation appears to be on the,

uh, mitral valve.

Uh, patient, uh, appears to have a large, uh,

right ventricle, uh,

and also there's some abnormal motion

to their ventricular septum, very prominent, uh,

diastolic flattening of the ventricular septum.

So when I saw this view, I already knew

from this view along that this patient

had severe tricuspid regurgitation.

I was pretty confident, even if I didn't know their history

of tricuspid, uh, valve, uh, endocarditis,

that would still be a reasonable,

as be a reasonable assumption

to make just looking at this view.

And the reason why is if you didn't even know their history,

uh, you can look at the, uh, mitral valve

and you say, okay, this is their,

they have a vegetation on the mitral valve.

The right side is enlarged,

and you have this diastolic flattening of the septum.

That diastolic, flattening of the septum is a textbook sign

of volume overload.

And one of the things

that can cause volume overload is severe

tricuspid regurgitation.

Next slide, please.

And so, if you're not familiar,

what volume overload looks like, you know,

you have pressure overload and you have volume overload.

And, uh, one of the differences is, is when the, uh,

flattening of the septum occurs, you have that dha, uh, sep,

uh, septum, but the flattening occurs during diastole,

and you notice, uh, it returns back to a round shape

during systole, the systolic goes back round, okay?

When you have pressure overload,

the septum stays flat throughout systole and diastole.

Okay? So this patient has very prominent flattening of the,

uh, ventricular septum during, which is a textbook sign of

RV volume overload, or RVVO.

Next slide, please. And here's what it looks like on M mode.

Next slide. Put

color in the peroneal view.

And surprisingly, there was no regurgitation

on the mitral valve.

Next slide, please. Here's the RVIT view

showing a very large, uh,

mobile echo density attached to the anterior leaflet

of the tricuspid valve.

Next slide, please. And we add color.

You see a lot of turbulent color, uh, flow in that area

between the, what would be the septal leaflet

and anterior leaflet.

And when I did continuous wave doppler,

you see a triangular shaped envelope, which is consistent

with, uh, severe tricuspid regurgitation.

Go to the next slide, please.

And, uh, you know, these zero more views,

uh, of the vegetation.

Uh, you know, it was, this is one of the big bigger, uh,

vegetations that I have seen, uh,

since I've, uh, worked here.

And it's, and it's kind of, it is weird that, you know,

this patient had the debulking procedure

and was put on antibiotics,

and he still has this massive, uh, vegetation.

Next slide, please. And then another sign of, uh, severe,

uh, tricuspid regurgitation where you would see

systolic flow reversal in the hepatic vein.

And that's demonstrated nicely here

with the pulse wave Doppler, uh,

image on the right side of the screen.

Next slide, please. And here is a good, uh,

image of, uh, a 3D image of the, uh, vegetation.

And it's, everything is nicely labeled for you.

And if you look closely, you can see how it oscillates.

Uh, when it comes towards the screen,

there's this oscillation, uh, which is consistent with, uh,

a tricuspid, uh, valve vegetation

or a vegetation in general.

Next slide, please. And then we add color

showing the, uh, regurgitation coming, coming, uh, in,

on the atrial side of, of the valve where the, uh,

septal leaflet, you really don't see much

of a septal leaflet.

Uh, looks like the endocarditis has eaten away a lot of

that, uh, septal leaflet.

And that's where a lot of the, uh, regurgitation is,

uh, coming in at.

And you can go to the next slide.

And I guess we can pause here for, uh, questions.

We said they were gonna do it here at the halfway point.

Uh, we might be a little bit past the halfway point,

but if there, are there any questions that

have been asked that we can address?

Yeah, I've scanned, uh, through the comments.

Um, I didn't see any specific questions.

I put a little blurb out there saying, feel free

to post any questions for mid end post lecture, uh,

discussion, uh, since I'm not seeing it, uh, Billy,

talk a little bit about, um, um, uh,

jet lesions and,

and where you see those re vegetations occur more on low

flow state of the, of the, uh, heart valve

or high flow state.

Where, where do you see them?

Right. You see it more on the,

on the regurg ti reg regurgitation side of a valve.

So for example, like on the, uh, the, uh, mitral

and the tricuspid valve where the leak, uh,

flows in the direction that it flows, that's normally

where you'll see a vegetation on the atrial side

side of the tricuspid and the, uh, mitral

and, uh, on the ventricular side

of your aortic and pulmonic valve.

Because when you have regurgitation on your aortic

and pulmonic valve, it typically leaks

back into the ventricle.

And that's where you see, uh, these vegetations

And the, and the pathogenesis of, of how

that occurs is really, is when you get a, a jet lesion

or a place where, uh, endocarditis is forming.

Um, it's really

because there's already been, uh, subcellular disruption,

and that creates kind of a host bed for that, uh, uh,

vegetation to begin to occur.

Exactly. Yeah.

Okay. Well, if we don't, uh, have

any other questions, I'm gonna keep things moving here

so we can, uh, get through.

And then, you know, we might have some more questions on the

end on, uh, I want, I don't want to keep people past, uh,

eight o'clock if I can.

So this patient, uh, some, uh,

this is a per sternal long axis view from a 60-year-old

female with a history of metastatic pancreatic cancer.

Okay? And, uh, recent stroke, uh, the echo was ordered

for her post-stroke evaluation to determine the, uh,

source of emboli.

So oftentimes, whenever a patient has a stroke, you know,

a echo is ordered, and depending on their history, you know,

their concern for either endocarditis

or, you know, some type of thrombus

or if the patient may have a PFO

or something along those lines.

So the first thing I noticed, uh,

on this patient, uh, was unusual.

There, there was some abnormal thickening, uh,

in the LVLT on the leaflets of the, uh, aortic valve.

Uh, that's the first thing that, uh, caught my attention.

If we can go to the next slide,

and I kind of zoomed up on it some more,

and you can see it better here from the, the,

the zoomed image.

You can see, uh, a lot of echo densities there.

It's real thick where you look close to the valve.

And then it looks like some fiber fibrous, uh,

fibrin strands, uh, that it's attached to it.

It's kind of going, uh, out, uh, back

and forth through the, uh, LVLT.

Next slide, please. And I looked at the same,

uh, I looked at the,

a tic valve from her apical five chamber view as well,

still seeing the same structure.

And look, we can, we like see

the strands a little better here, where it extends into the,

uh, LVLT hitting the, uh, mitral valve.

Next slide, please. Then, um, you go to the biplane image,

and it allows me to see it a little better, see more of it.

Uh, again, it's very fibrous, uh, echo density.

It is right, right up against the, uh, aortic valve.

Next slide. And there is a little bit of, uh,

aortic regurgitation.

Next slide. And I did, of course, a 3D image of it

and allowed me to see more of the, uh, the, uh, echo density

and the aortic valve and the surrounding structure.

So it's just didn't see, I didn't see anything on the, any

of the other valves, so

that's why I'm just showing you the aortic valve.

I looked at those valves close closely as well.

And, uh, typically when there's, uh, stroke involved,

uh, it, it's a, a left sided, uh, issue of the heart.

So you weren't willing to pay close attention to the, uh,

you know, the valves on the left side of the heart.

You wanna look at all your valves,

but you should be more suspicious of, uh, left-sided, uh,

valve structures and or if they have a, uh, PFO.

So what this patient had was, if you go to the next slide,

is what they call meic endocarditis.

Now, this is a non bacteria type

of endocarditis is more thrombotic.

Um, and basically thrombi will, uh,

you'll see thrombi form on a valve,

on a undamaged valve without the presence

of, uh, bacteremia.

So these patients, uh, they're not, uh, they don't have, uh,

positive blood cultures.

Uh, but it's, it's very rare.

It's mostly seen in patients with advanced mal malignancies,

like such as this patient.

And it is associated risk with, uh,

multi-systemic, uh, emboli.

So this was the, uh, cardiac source of emboli

that the, uh, echo was ordered.

I think they ordered a bubble study as well,

but we didn't do the bubble study

because, uh, we were pretty confident that we found the, uh,

uh, cardiac source of M bli.

Next slide, please. So this will be the

final case for tonight.

Next slide. So this patient has a very, uh,

interesting, uh, history.

Here is a 64-year-old male with history of hypertension,

thyroidism, also a, a hernia repair.

They presented with a, with volume overload.

They had a lot of edema.

They had bilateral pleural effusions

and a new diagnosis of heart failure and cardiogenic shock.

Echo was done on the 16th of February

that showed an e ejection fraction of 15 to 20%.

They, they did a, a cath on them,

but they didn't find, uh, anything, any disease

that correlated with the, uh, degree of, uh, LV dysfunction.

He had some disease, but it didn't, uh,

represent the severe LV dysfunction that this patient had.

Next slide. So they were thinking the likely, uh,

reason for this patient's heart failure was something

that they described as being tachycardia

induced cardiomyopathy.

So they consulted EP for his, uh, AFib

and RVR.

He later developed a cough

and tested positive for respiratory virus,

and he was transferred to the micu, uh, for septic shock

and MRSA bacteremia.

They did a checks x-ray

and showed some patchy opacity concerning for, uh,

postviral bacteria, PMO pneumonia.

And they ordered an echo

because of the bacter bacteremia on the 28th.

And here's what this echo showed.

So I'm gonna show I did. Uh, so this patient had two echos.

I, the first echo was done by my coworker,

and I did the echo 12 days later.

And here. So I'm gonna do it like a side

by side, uh, comparison.

So pretty much the, the function looks the same, you know,

on initial echo as well as 12 days later.

Next slide. And, uh,

the only difference that we're seeing now is this patient

has regurgitation.

There was really no regurgitation before.

Now we have this new regurgitation. Okay, next slide.

And if we zoom up on the mitral valve now,

even though we didn't see this mobile echo density on the

valve as we see, uh,

12 days later on the 12 days later side.

And the reason we didn't see it is

because how I was angled, uh, depending on

how you're angled in these views,

you'll see different structures.

And this view to bring in the vegetation,

I kinda angled the probe upward, uh,

towards the aortic valve, where you will bring in like, um,

a one and P one.

And, uh, that's where I start seeing this,

uh, vegetation here.

Next slide, please. And if we look at the per sternal short

axis of the mitral valve,

and you see a difference, uh, 12 days later,

you'll see some thickening on the, uh,

anterior lateral commissure in the area of, uh,

A one and P one.

There's some thickening there, uh,

that you didn't see in the initial e uh, echo 12 days ago.

And next slide, please. And when I add color, you,

you see, not only do you see mr, but it's paravalvular mr.

There's, there's a, uh, jet that's actually outside

of the leaflets there.

Next slide. And we show the, uh,

apical four chamber view where there really wasn't much

or any, uh, MR initially.

Now we see quite a bit of mr, it actually,

it's going all the way to the back of the left atrium, uh,

which is consistent with, uh, severe mitral regurgitation.

Next slide. And, uh, this is just, uh,

like a apical five chamber.

I'm kind of angled to bring in the

vegetation a little bit better.

And you can see that there's not only a vegetation,

but there's some dropout there like in the middle

of the vegetation, which would be considered of, uh,

cons consistent with perforation.

And that's what we were seeing in the other views as well,

where that, uh, jet was outside of the area of the valve,

outside of the annulus.

Let's go to the next slide, please.

And we put color, and this is from a two chamber,

and you can see again where that jet is severe, Mr.

Next slide. And I measured a PISA

and I got a ERO of 0.6,

and a regurg of volume of 79 milliliters,

which is consistent with severe Mr.

Next slide.

And I did a 3D, uh, assessment as well.

Uh, and I got the same thing with my 3D.

When IP to the vena contracta, it was, uh, 0.6, uh,

millimeters, uh, squared as well, which is consistent

with severe mitral regurgitation.

So this is a very, very interesting case.

Uh, oftentimes when echoes are ordered for patients

where they're suspicious of endocarditis, you know,

they'll have serial serial echoes

where we're consistently doing echoes on patients.

And sometimes, you know, we get kind of frustrated like,

wow, this patient just had an echo a few days ago.

I mean, if it wasn't anything there,

then there's definitely not gonna be anything there now.

And that was kind of my thinking initially when I was

going do this echo.

I was like, man, you know, 'cause you know,

we are a very busy echo lab

and you don't wanna be doing repeat echos for nothing.

Uh, you wanna make sure there's a good reason.

So I, you know, I was looking in their history

and their, I was seeing that, you know, they had,

they were getting worse.

Their status had kind of changed since the initial echo

'cause official, uh, first I was just

gonna just, just do a limited.

So I went in and did it and I saw this

and I wasn't expecting it.

And it's just very, very, uh, it's kind of scary

how quickly, uh, someone's, uh, someone can change

how quickly things can change.

Just 12 days ago, there was no regurgitation.

Now this patient has severe mitral regurgitation

and a veg vegetation and a perforation,

and all of that happened in less than 12 days.

So even though I did the echo, you know,

the echoes were done 12 days apart.

This, you know, this probably more than likely happened

in less than 12 days.

So it's, uh, pretty scary.

And this, you know, this is an example again, of a patient

that didn't have any history of, uh, IV drug use.

Uh, and they developed this while they were in-house.

You know, they came in and developed all this,

the endocarditis and the vegetation and everything.

Uh, so it's not always, uh, IV drug use that, that, uh,

causes, uh, endocarditis.

Go to the next slide, please.

So this brings me to my last slide, uh, being that most

of the patients that do develop endocarditis, unfortunately,

is due to, uh, IV drug use.

And, uh, and just it's important to understand that,

you know, people who are addicted, uh, who have trouble

with addiction, it, it's an illness.

Okay? You know, we, you know, they, they, they do things

that don't make sense because of their illness.

And this quote kind of like really sums up everything.

This is, I don't know who, where this quote is from,

but it says, addiction is giving up everything.

For one thing, recovery is giving up one

thing for everything.

Uh, and that pretty much sums up, uh, addiction.

And, uh, that completes my presentation,

and I hope you enjoyed it.

And like I said, if you have any questions,

please submit your questions.

Okay. We, we do have some questions

that, uh, we can go over.

Uh, someone asked, uh, what would be considered, uh,

a higher risk vegetation ver versus something

that's of lower risk?

Uh, I, I personally would add that I had a case one time

of an aortic valve, uh, vegetation.

Uh, and it was undulated with a very, very small stalk.

And as that valve leaflet was moving

and things, this, this pedunculated uh,

vegetation was literally

flopping from one side to the other.

I'm, I'm like, to myself, I'm saying,

okay, this is high risk.

'cause it's about ready to break loose. Right?

Nowhere. I would agree. Yeah.

Any, the highly mobile vegetations,

I would think would be at higher risk.

Anything that's, uh, at a higher risk of embolizing,

you know, it's, it's, it's life threatening.

It's more life threatening as opposed

to something that isn't.

And of course, I would think the highest would be anything

that's on the aortic valve,

because that's right there, that's like a direct path to

that can be like a direct path to your brain.

Any little piece

or thing that breaks off, it's,

it can go straight to your brain.

So that would be my, uh,

my answer to that question. Yeah,

I'd agree with that too. Yeah.

Uh, another question was, uh, does poor

lv uh, function contribute

to the development of endocarditis

Poor LV function?

Uh, I don't think it can.

Uh, I'm not sure if it really contributes to, uh,

the development of, uh, endocarditis.

Uh, but it can be a sign, an indirect sign of endocarditis,

someone who's dealing with sepsis, very sick.

Uh, right. I, I don't, I don't, yeah.

Yeah, I don't know of any, uh, specific associations.

You know, if somebody doesn't have other risk factors,

that's, that's probably not gonna be, you know,

a direct cause or contribution.

I another person, uh, chime in

and say, uh, we don't have 3D in our lab.

What, what, what are the best approaches

and best tools for us to utilize, uh, to evaluate, uh,

for endocarditis without the 3D access?

Sure. Just, just use what you have.

You know, you, you're a skilled professional.

Uh, anything, anything that you can do to, to visualize the,

the valves as best you can.

Like I said, high res zoom, you know, go

through all the views of the anatomy.

Like the tricuspid valve can be seen from multiple views.

You know, you want to pan over it, you know, as, look at it

as closely as you can to try

and see as many of the fine details as you can, uh,

you know, be real suspicious when you see color,

especially if you know the patient didn't have any

regurgitation, uh,

before all of a sudden now they have

regurgitation, you know, things like that.

You, yeah. You can only use what you have, you know,

and I, I show those examples

because yeah, I'm fortunate to work in a lab

where you have all these tools

and I, you know, I like to use everything that,

that the machine can do.

Yeah. Your, your number one weapon is the high

index of suspicion.

I, I, I like that, Billy.

And, um, using, you know, yeah,

you're gonna get these specific views,

but if you use some compound views

where you're in multiple planes, you can really, you know,

creep into finding these recesses

or, you know, using some things

that may not be traditional if you have

that high level of suspicion.

Mm-hmm.

Another question, any problems with reimbursement?

Uh, with, of 3D? Uh,

Uh, not to my knowledge. Uh, I don't, yeah,

Not to my know That specifically,

but I haven't, uh, I don't,

I don't know any knowledge of of that.

Any reimbursement for that? No.

Yeah. I mean, if there's a, a question of reimbursement,

there's a problem with it, you know, just in general,

you know, there, there, I'd say most reimbursement problems

come from coding and, and, um, you know, just the report.

Not saying, you know, correctly what the technique was used.

Mm-hmm. Yeah.

So, yeah, just another quick note on, on the 3D,

like in our lab, the, the only, uh, thing

that we're required to do as far as 3D is, uh, full volume

for, uh, EF assessment.

Uh, anything else is just whatever, you know,

they, whatever you want to do.

And, you know, I, so I, I always, I'm just kind of like,

I go above and beyond, you know, I go,

I do more than what's necessary.

Uh, that's just kind of how I am.

And that's just how I keep things interesting.

You know, I've been doing this job for like 16 years

and, you know, you can't get kinda routine and,

and, uh, to you sometimes.

Uh, but using the 3D it just keeps things interesting and,

and fresh for me.

And that's why I like to, uh, promote it so much.

What would be your feeling on, uh, uh,

utilizing the same sonographer to continue to reevaluate,

uh, uh, follow up studies on the those same patients?

Uh, yeah, that, that can be helpful, uh,

because, you know, like I said, do, doing echo is a skill,

and 3D imaging is a, is a, an an advanced skill.

And sometimes, you know, especially

'cause o one example, like in our lab, we, we were, uh,

part, we are a part of a, uh, research for this, uh, device

that they use to treat tricuspid regurgitation.

And part of that protocol for this research, uh, was

to do a lot of 3D imaging of the tricuspid valve.

And we really didn't have many sonographers in her lab

who had any experience at all other than myself.

So I volunteer myself to, you know, jump in and,

and do as many of those as I can.

And I, you know, to teach others what I know to try

to bring them up to speed,

because yeah, it can be overwhelming, uh,

if you've never, uh, done it before.

And I, I think it's, uh, yeah, it, it does make sense.

Just like other things too, with echo,

sometimes you have special pr

Endocarditis Unveiled: Beyond Vegetations Avoiding Critical Mistakes)

Chapter 1