Transcript

Welcome everyone to our July webinar on

MI complications today.

So we're delighted to have you join us today.

My name is Joanna Bueno,

and I'm the program director at IAME.

Uh, I'm gonna be here hosting the session with you guys

and with our special speaker today.

That is Billy Kathy.

Uh, we're gonna go

and check some of the, some of the, uh,

information about the webinar,

and also I wanna talk about, um,

some key points, uh, for members.

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and everyone they have, like this webinar has open access.

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Um, and let's go ahead with, uh, the

accreditation and designation statement.

This activity has been planned

and implemented in accordance

with the accreditation requirements

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for continuing medical education.

A-C-C-M-E-I-A-M-E is accredited

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IAME designate this live online webinar for a maximum

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physicians and attendees should claim only the credit

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So you gotta wait until the last second

disclosure summary.

In compliance with the essentials

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

of the CME activity is required to disclose

any significant financial

or other relationships they may have

with commercial interest.

Jason Cox, MD

and Billy Kathy, uh,

disclose no such relationship exist.

IAME has assessed conflict of interest with its faculty,

authors, editors, moderators,

and any individual who were in a position

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Any identify relevant conflicts of interest

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Im E'S planner. Content reviewers

or editorial staff disclosed, no, no relationship

with eligible entities.

So, with this said, I'm gonna,

I'm gonna invite Billy Kathy

to the stage. Hi, Billy.

Hello, Joanna. Thank you for the, uh, introduction.

Good evening everyone.

Thank you for, uh, tuning in tonight, uh, to hear this, uh,

webinar on mi complications, aneurysms,

and, uh, ruptures.

Okay, I want to thank you.

Thank you, Billy, uh, to be

with us today in this July webinar.

I also wanna mention

that Billy Cathy is experienced cardio sonographer

and is the president of the MCSS Association.

So it's good for you to know that we have our

pickers, uh, we have speakers with a lot of experience,

and they are willing to share with you guys

everything about the topic we are talking today.

That is in my complications.

So, Billy, uh, the audience is all yours.

Okay, thank you once again.

Alright, we'll go ahead

and get into our topic, uh, this evening.

Uh, once again, the, uh, topic tonight is mi complications,

aneurysms, and, uh, ruptures.

Um, go to the first slide here.

Um, whenever someone has a heart attack, uh,

they can have many, uh, complications.

Anything from LV dysfunction, there can be ruptures.

You can have a thrombus pericardial effusions.

Uh, it's a multitude of things that can go wrong

after someone has a, uh, myocardial,

myocardial, uh, infarction.

Uh, but tonight, uh, we're gonna talk about some

of the mechanical complications

that these patients sometimes have.

Uh, we're gonna talk about aneurysms, pseudo aneurysms,

and, uh, VSDs.

So first we're gonna talk a little bit about the different

types of infarctions.

There are several different types, uh,

that a patient can have.

Uh, if you look at this, uh, illustration here,

it shows you, uh, the different ones.

You can have a sub endocardial infarction

where the infarction is just below the, uh, endocardium, uh,

can be a transmural infarction, well, where the infarction,

uh, will travel through all layers of the, uh, myocardium

out into the pericardium.

And it can be an intramural infarction,

or it's just in the, uh, within the, uh, myocardium as well.

And, uh, then you can have a sub epicardial infarction, uh,

that extends, uh, out from the, uh, pericardium.

So the patients that, uh, have a VSD

aneurysm or pseudo aneurysms, uh,

they will have a transmural infarction

where the infarction goes through all layers

of the, uh, myocardium.

And, uh, whenever there is an aneurysm,

uh, it causes thinning

and remodeling of the ventricular wall.

And it often, uh, occurs in the apical region,

but it can, uh, appear, uh,

anywhere throughout the, uh, ventricle.

And some complications from the aneurysms can be a thrombus

formation as well as, uh, ventricular arrhythmias.

So, aneurysms bulge outward when other

sections contract.

Uh, aneurysm can be described

as a distinct break in the contour of the ventricle

that is present in both diastole and systole.

And here's a nice example of a apical aneurysm.

So whenever we're assessing, uh, a patient for aneurysm,

especially the apex, it's one thing that's important

to remember is not to force shorten.

Uh, whenever you force shorten, uh, a image,

you can miss a aneurysm.

So you wanna make sure that, uh, you know,

that you're showing all of the apex

and it's as best you can.

And, uh, sometimes to do that, it can, to help do that, it,

you can reposition the patient, either have them roll, uh,

more onto their left side.

If you're fortunate to be in the lab that has a cutout, uh,

in the bed where you can get more lateral,

that can be very helpful as well.

So this is an example of force shortening.

Uh, as you can tell, you can look at these two images.

This is the same patient.

Uh, the image on the left side of the screen, of course,

is four shorten, and the, the image here on the right isn't.

So, uh, this, this is an echo that I did bedside.

And so when I initially started, you know,

I had a difficult time, uh, you know, being

that this was a bedside, uh, patient.

Uh, these are ones that are hardest

to get good apical views on,

because a lot of times you can't position 'em the way you

need to position them.

And it's hard to get lateral, uh, because of the bed.

You don't have that dropout where you can get under there

to really see the apex like you, uh, need to see it.

So if you're kind rushing

and just trying to get through an echo, a lot

of times people will be satisfied with this image

and continue on.

But I, you know, I was a little more determined

and I got a little more, uh, lateral,

and I was able to see this unfor shortened image, which show

that there is a thrombus in the, in the apex

Contrast is also very useful and important

whenever you're assessing a pa.

Assessing a patient for a aneurysm allows you to see,

uh, the endocardium better,

and you also helps you rule out any thrombus, uh, in there.

And of course, it can, uh, also help, uh,

determine if this is a pseudo aneurysm or a true aneurysm.

So this is just a nice, uh, model, uh, 3D uh, model showing,

uh, how a heart with a apical aneurysm contracts, you notice

that the, uh, a apex contracts,

uh, you get a better appreciation of how the apex

apex gives a larger contraction when the lv, uh,

contracts showing a lv uh, aneurysm.

And here is a, uh, massive apical, uh, aneurysm.

Uh, this particular patient,

you don't really see much motion at all that the, uh,

the section, the apex stays the same throughout

the cardiac cycle.

Uh, you also are seeing, uh, spontaneous contrast, uh, due

to the decreased function in the, uh, the, uh,

stagnant blood flow in this heart.

And it's something that you'll see in patients

with aneurysms and, uh, pseudo aneurysms.

Here's another example of a patient with a, a, uh,

apical aneurysm.

Uh, it's very focal towards the, uh, apex patient also has,

uh, LVH,

but you can see that the, uh, apex pulsates

during systole,

and it's also has a, uh, laminar thrombus in it as well.

And I got a 3D image of the apex, again, showing the,

uh, how it's pulsating.

And, uh, this is, uh, on the right side, you see a, uh,

a cadaver, a specimen from a pa uh, patient, a patient

that actually had a, uh, an aneurysm.

And you can see how the, uh, 3D image

gives you much more detail, uh, about the structure, uh,

of the, uh, aneurysm.

Something that you won't see with the 2D image.

And of course, for all of you that know me, I,

I really like utilizing, uh, 3D and I like to promote 3D

and try to show people how it can help you, uh, when you go

through your echoes and allow you to see things

that you wouldn't normally see

and gives you a better appreciation, uh, with the details

and the things that you can see.

And you can see how it is a better representation of

what the heart truly looks like, as opposed

to looking at just 2D images.

So patients that have aneurysms, they have a tendency

to develop a thrombus, as you see in this image here,

this particular patient didn't have a aneurysm,

but they did have a, uh, apical thrombus due to the, uh,

wall motion abnormality in the apex.

And a lot of times, these, uh, thro thrombus,

they can be either la laminar, poculated or mobile.

So now we're gonna talk a little bit about pseudo aneurysms.

Now, pseudo aneurysms are basically a ruptured,

uh, LV rupture, a contained rupture, basically.

So you have a rupture along the free wall

that has bled into the pericardial cardium,

and it's contained by either clot or thrombus.

And it most commonly occurs, uh, after a heart attack,

but it can also happen due to trauma or cardiac surgery.

And, uh, it can be described

as an acute angle, excuse me.

And a, an abrupt acute angle is often seen

between the normal myocardium and the aneurysm region.

Uh, a small neck con connects the ventricular cavity

with a wall off, uh, pericardium, parti pericardial space.

So it's important to distinguish a

pseudo aneurysm from a true aneurysm.

Uh, pseudo,

an pseudo aneurysms typically have a neck to them.

Uh, and when you put color doppler in the neck,

you'll see bidirectional flow going in and out of that neck.

And, uh, you'll also see spontaneous contrast

and thrombus, uh, within the pericardial space.

And pseudo aneurysms often occur in either the inferior

posterior wall or the, uh, lateral, excuse me,

the inferior lateral and or, and, and,

and then the, uh, apical wall in it order most commonly in

the inferior posterior,

then inferior lateral, then the apical wall.

So this will be the, uh, uh,

inferior posterior wall in here.

Uh, this, uh, segment here, number 10 here in the, uh,

short axis view of the LV here in the bull's eyes,

where you'll see the inferior posterior wall.

And you'll all see, see the inferior posterior wall in

the two chamber here.

And now the inferior lateral wall will be located here,

number 11, and the, uh, short axis of the LV

bullseye here.

And, uh, and the long axis here.

So depending on, you know, what view you're in, uh, will,

uh, sometimes, uh, dictate whether

or not, uh, it is a pseudo aneurysm or a true aneurysm,

because it's more, uh, often in certain segments

of the heart, uh,

but sometimes it can be challenging to make

that a determination.

But the most important thing about making this distinction

is when a person has a pseudo aneurysm, they had a,

they are at a very high risk of, uh,

rupture and sudden death.

So it's very important to

truly determine if the patient has a pseudo

or a, uh, true, uh, aneurysm.

And this illustration here

pretty much shows you the difference between the two.

It's, uh, with a pseudo on here on the right, you'll see

where the rupture has gone through all layers

of the pericardium out, excuse me, all layers

of the myocardium out into the pericardium

forming this bubble that's, uh, layered with thrombus.

And here, you'll, you see all layers of the myocardium.

They're just stretched and thin out and scarred, uh,

but there's no rupture.

Uh, and a lot of times you'll see thrombus there.

So again, basically the, the pseudo, the biggest difference

between the pseudo

and a true aneurysm is

that the pseudo aneurysm is basically a contained rupture.

And that's why they're,

these patients are at a very high risk of sudden death,

because if this contained rupture, uh,

ruptures again, more so it can, you know,

they can bleed into the pericardium, go into tamponade,

or if it bursts, if the pericardium bursts,

they'll just bleed out

and die, you know, so it's, it's a very serious thing.

So this is an echo, uh,

that I did this first case here on a patient that, uh,

had a, has a pseudo aneurysm.

It was already known. Uh,

and just here, I, uh,

this is the per sternal lung axis view,

and I just wanted to show, uh, show these, uh, two

pictures side by side, because it's the same patient.

The only difference between the image on the left

and on the right is just

how I manipulated the, uh, transducer.

I just angled a little bit more to bring in this, uh,

posterior wall, and you can see the aneurysm here.

Going to the next slide, I've, I put color,

and you can see, uh, color going in

and out of this, uh, structure here showing, uh, the, uh,

signs of pseudo aneurysm.

And I use the, uh, biplane image as well.

So not only, uh, do I like using 3D,

but I also like to use the biplane imaging.

Uh, it's very helpful

and useful when, uh, trying to look at something

and determine, uh, if it's an aneurysm or pseudo aneurysm

or exactly where the, uh, aneurysm is

being that this patient has a pseudo

aneurysm, which is known.

Uh, when I put this cursor here,

and it gave me the view of the, the orthogonal view,

which is the left ventricle

and short axis, it allows me to see, uh,

where the pseudo aneurysm is.

If you look carefully here, you see this little dropout,

which is the neck, and it's

where it's going into this aneurysm here.

So this is an inferior posterior aneurysm.

You can see it clearly here be

because I, uh, use the biplane image.

And one thing that's good about using the biplane as well,

this cursor can be moved.

You can actually sweep through, uh,

the short axis while you're in the long axis

and see it, you know, simultaneous in real time.

And that's very helpful when, you know,

looking at things such as an aneurysm.

So when I pulsed there, I didn't really get much flow.

Um, you don't always get good flow, uh,

through the aneurysm,

but, uh, especially if you're not lined up parallel to flow.

So, but there is some flow going in

and out of the, uh, that structure.

So this patient, as you can see,

doesn't have very good apical windows.

This is me showing a two chamber.

And in the two chamber, we can see that there's some, uh,

you know, wall motion, wall motion abnormality here in the

basal area in the mid area.

And then as I rotated a little more off axis, you start

to see the aneurysm come into view.

So, off access imaging is important as well.

Whenever you're trying to look at for a pseudo aneurysm,

or to look, or you're trying to evaluate for an aneurysm

or a pseudo aneurysm, uh, you need to pay close attention,

uh, especially as you're rotating from one view to another.

Like as, as you're going from a four to a two

or two to a three, just pay very, uh, close attention,

because sometimes it's gonna require you

to really go off axis to see, uh, the aneurysm.

Here's the three chamber with and without, uh, contrast.

You can see it here, the aneurysm.

And then you can see contrast going into the aneurysm, uh,

on the, uh, right side of the screen.

So even though this patient didn't have the most, the best,

uh, apical windows, I was still able to get a beautiful 3D

uh, image of the, uh, pseudo aneurysm.

So if you look very carefully, I have it, uh,

labeled nicely for you.

Uh, this is, uh, a two chamber view.

So you have the mitral valve here, uh, left ventricle here.

Uh, this is the, uh, basal, inferior wall.

And here's, you can see the neck of the, uh,

pseudo aneurysm very clearly.

Here you see myocardium coming all the way down from the

apex to about this section.

And you see this big gap here, this, uh, echo free space.

This is the neck, uh, of the pseudo aneurysm,

and this is the aneurysm itself where the, uh,

pericardium is the contain, uh, rupture.

So when you do 3D uh, imaging as well, uh, you allow,

allows you to do a multis slice reconstruction.

So, looking at the, uh, multis slice reconstruction

of this patient, again, it allows me

to more accurately visualize the origin

of the pseudo aneurysm.

And I can also see how far up it goes, uh, on the, uh,

ventricle outside of the ventricle.

The, the bubble, uh, goes up, uh, outside of the ventricle.

So you can see here that the, the,

in the inferior posterior wall of the LV is where the neck

of the, uh, pseudo aneurysm begins.

And it tracks all the way up to here, uh, close to the apex,

uh, of the, uh, lv.

And typically, this is something that you normally see, like

only see on a CT scan.

But now with 3D uh, the 3D capability that we have, uh,

on our transthoracic uh, machines, we can get these images

and, uh, they can be utilized, can be very helpful,

uh, in your studies.

So we're gonna go to our next case.

Uh, so I'm just going to,

before we get to the images, I'm gonna try

to establish a timeline on this, uh, particular patient.

He has a pretty, uh, extensive history here.

So in February of, uh, last year,

a 51-year-old male present presented

with less left sided chest pain.

Uh, the echo that he got showed that he had extensive

an extensive area of anterior apical

and distal inferior kinesis with an, an aneurysm formation

and laminated apical thrombus.

His EF was visually estimated to be about 30%.

Uh, this patient was placed on a balloon pump while they

were, uh, evaluating him for surgery.

Uh, while, uh, while he was still in the hospital,

he did receive, he had a cardiac MRI, which showed a large

apical true aneurysm with mural thrombus.

Uh, the aneurysm volume was calculated to be 28, um,

excuse me, 284 milliliters.

So that's a huge aneurysm, uh, uh, anterior septal

and apical wall transmural infarct with regions

of microvascular occlusions.

So his surgery was deferred.

Uh, since the MRI showed that he had a true aneurysm,

not a pseudo aneurysm.

Uh, he was later taken off the balloon pump

and discharged with a life vest.

Uh, throughout his follow-up visits with his car,

Cardi Cardiologist, um, as an outpatient,

the patient was experiencing progressively worse, uh,

worsening dyspnea on exertion.

Uh, on in May, uh,

on May 25th, 2023, due to his worsening, uh, heart failure,

he was strongly encouraged to be admitted

for advanced therapy.

So now, during this time,

after he was initially, uh,

released from the hospital in February, uh,

with the life vest, he actually returned back to work.

But, you know, he was still very sick,

and he was just getting, uh, worse and worse over time.

And when he went to visit his doctor in May, you know,

the doctor wanted to admit him then,

but he wanted to, he didn't agree to being admitted,

he wanted to think about it.

So six days later, the patient was admitted into the,

uh, ed, ed.

And, uh, shortly

after his admission, uh, on the 1st of June is when

I did, uh, this echo, this images,

uh, that you're gonna see.

So we're gonna start here with the parasternal long axis.

And as you can see, he has a massive, uh,

aneurysm here, uh, of the, uh, left ventricle.

You really don't see, you're not seeing the, uh,

right ventricle at all.

This little slit here is where the, uh,

right ventricle is being compressed by this huge,

uh, aneurysm.

And here's a biplane, uh, image.

You can see the, uh, spontaneous contrast,

and you can see the, uh, short axis of the AEUs.

You see this echo free space here where it, the, uh,

the aneurysm is going up

and over the, uh, right ventricle here it is in short axis.

You see by that bi-directional flow going, uh, in

and out of the, uh, area here.

And when I post that area in the four chamber view,

I was able to get this bidirectional flow.

Here's a 3D image.

Uh, looking at the short axis of the, uh, left ventricle

here at the level of the papillary muscle, uh,

as I have it labeled here, you see this little dropout

that's going in, that's opening and closing.

This is what I believe to be the neck of a pseudo aneurysm,

not a true aneurysm, even though they said the, uh,

cardiac MRI was a true aneurysm, you can see the

spontaneous contrast here as well.

And here are the, uh, apical views.

Looking at the apical views,

it gives you a better appreciation of the full extent

of the aneurysm.

Aneurysm is so big, it's, it doesn't even fit on the,

in the, it doesn't even fit within the sector here.

It just goes off the, uh, screen here in the two chamber,

in the, in the three, uh, chamber,

just mushrooms, just massive.

And here you can get a better appreciation as well as

how the, how the RV is being, uh, distorted and compressed.

Here on the left side in the four chamber is laminar

thrombus, and you're seeing the, uh, spontaneous contrast

due the, to the, uh, stagnant blood flow.

So, uh, I, I, uh, did a multis slice view

and, uh, from the apical four chamber,

and from here, I was able to locate, well, what the,

what I believe to be the neck of the pseudo aneurysm.

If you look at this image here, you'll see this dropout

that's going in and out of view here at this area.

This is looking at the ventricle

and cross sections all the way from the base to the apex.

And then, of course, here is

where it really balloons out the, uh, aneurysm.

And here's some more views.

Here's a 3D view here, giving you a better appreciation

of the, uh, the spontaneous contrast.

This is the area, I believe, where the, uh, neck

of the pseudo aneurysm is.

Here is the, uh, laminar thrombus.

Here is the right ventricle.

Here's a, uh, looking down the, uh,

ventricle from the, uh, apex.

Uh, you can see the neck of the,

what I believe the ne be the neck of the,

uh, pseudo aneurysm.

And, uh, just to give you a little more backstory, uh,

on this, uh, so when I initially did the echo,

I was not suspicious of a pseudo aneurysm.

I read the patient's history that, you know,

he had a cardiac MRI,

and it was, you know, determined it to be a true aneurysm.

But, uh, af shortly

after I did the echo, I, uh, reviewed this echo with one

of the cardiologists in the lab.

And as we were going through the images, he was, uh,

very suspicious that this PA patient

actually had a pseudo aneurysm, not a true aneurysm.

And he was so concerned

that he actually had another radiologist re

reread the, uh, MRI

and that mri, uh, that radiologist agreed with him

and said that this patient had a pseudo aneurysm.

So this cardiologist notified the, uh, team that was caring

for this patient, and told him, Hey,

this patient does not have a pseudo aneurysm, I mean,

does not have a true aneurysm.

He has a pseudo aneurysm.

So after that, that's when I went back

and did, you know, put together some of these images

that you're looking at.

Now, had I known that this patient had a pseudo aneurysm,

I would've, uh, done a better job of trying to, you know,

locate it, especially with the doppler

and the color flow, uh, that would've been been a, you know,

a better, stronger, uh, thing to show someone.

But, uh, the good news about this patient is that, you know,

after about 14 days, uh, they,

this patient received a heart transplant,

and they were later discharged from the

hospital, and they're doing fine.

So, here's another case of a patient with a history

of a pseudo aneurysm re repair.

And I have it in question marks,

and you'll see why the question mark is

when you look at the views.

Uh, so this is the, uh, peroneal lung axis showing,

you know, reduced, uh, LV function, dilated LV and rv.

And, uh, when I, here's a peroneal lung axis as well,

with a focus view of the apex,

I mo moved a little more lateral, uh, on the patient's chest

to bring in the apex a little bit better.

And, uh, you can see here that there's a

echo free space here.

There's also a mobile echo density bouncing in and out.

And then you have this area here that kind of balloons out,

uh, from the apex.

So this looks like a pseudo aneurysm.

It does not look like a repaired pseudo aneurysm.

So I don't know what, what happened

or what kind of repair that they did,

but this is what I saw, which was very alarming.

Uh, so, so basically what I believe this, this looks like,

uh, a rup, you know, piece of the ruptured, uh, myocardium

to me, that's what it looks like.

Um, I'll show you some more views with color.

You can see color flow going across there, that area.

And this is the apical four chamber.

So, uh, when I went to, you know, do a apical view, you,

you can just barely see the left ventricle

because the pseudo aneurysm is so massive.

It just covers this whole side of the screen here.

And you see this just packed with thrombus here.

And then you can see the neck.

And this is the area that we were seeing in the, uh,

long axis view here.

And then with color doppler, of course,

you can see flow going in and out, uh, of that area.

And this is the same patient just showing you what a

for shortened view would look like.

Just to reinforce that point I was making, uh,

before the importance of not for shortening.

Uh, because when you, for shorten you,

you'll be surprised what you can miss.

You can miss a massive, uh, pseudo aneurysm, okay?

So be careful when, uh, when you're doing your images there.

And this is the same patient with contrast showing, uh,

contrast going into the, uh, pseudo aneurysm.

Now, this next ec, uh, echo is a patient

that has a apical pseudo aneurysm.

Uh, I did not do this echo.

A former coworker of mine

who doesn't work in our lab anymore, her name is, uh,

Jessica, uh, Hampton.

She did this echo, and she showed it to me,

and I was very impressed.

Oppressive demonstration of what a, uh, pseudo aneurysm, uh,

looks like, and how to evaluate, uh, a pseudo aneurysm.

So, just as

before, as in the, uh, previous patient, uh, you know,

it's in the apex.

And here on the right side of the screen,

she's showing you a focused apical view,

moving more lateral, uh, on the patient's chest

to bring in the, uh, apex.

And you can see this big flap here in the apex area.

And there's this dropout area at this part of the heart.

And using color doppler, you can clearly see flow going in

and out of this area, the bidirectional flow that you'll see

with a pseudo aneurysm.

And she captured it, captured it

with a continuous wave Doppler, showing it beautifully here,

this flow, which is textbook for a pseudo aneurysm.

And here is a short axis view on the left side

of the screen, uh, at the papillary muscle,

and then at the apex Color

flow at the apex.

Then here's what the four chamber look like, looks like,

again, showing bidirectional flow.

See pulse here, showing flow, going, uh, from the ventricle

through the neck into the aneurysm,

showing it again in the two chamber.

And again, in the, in the three chamber, a zoomed up view

where you can get a better appreciation of the dropout.

And, and you can clearly see, uh, the rupture site of the,

uh, pseudo aneurysm.

And again, the color doppler

and the pulse wave, uh, doppler.

So whenever you're evaluating, you know, you want

to look at, uh, you know, we, as part of

what we do when we do echo, we just don't use one view.

We just don't look at things in one view.

We use multiple views, multiple angles to, you know,

you want to give the, the doctors as much evidence

as you can, that you know, this is what you're seeing.

And sometimes, you know, don't be afraid, afraid

to go overboard if you, uh, need, if you feel that you have

to, because, um, unfortunately, you know, some I've,

I've experienced, uh, sometimes with some of the readers,

even where I felt I went above

and beyond to point out something

and then have them not commented, comment on it at all,

can be very frustrating.

Uh, so sometimes, you know, you have to go above and beyond.

And then still, if you're not satisfied, if they don't agree

with you, you know, always follow up.

You know, give them a call, uh,

send 'em a message, you know?

And if you really feel strongly about something,

especially like a pseudo aneurysm, uh, you, you,

you wanna make sure that that is known and,

and that is, uh, taken care of

because it's such a life-threatening, uh, situation.

So, another complication that, uh, patients can have, uh,

post mis VSD.

Now, this increases the risk of mortality,

and it occurs, uh, with usually within the first three

to six days, uh, after, uh, a heart attack.

And some of the risk factors are patients

that are older than 65 have a history

of high blood pressure, female.

It's their first heart attack.

It's a single vessel, uh, uh, disease, uh,

and it's, and they present with, uh,

recurrent chest pain and hypotension.

Uh, after se, several days, excuse me, several days

after they've had a heart attack,

they'll have these symptoms of, uh, recurrent chest pain

and, uh, hypotension.

And you'll have things like a new

harsh systolic murmur and thrill.

Uh, typically it's LAD and r.

It's, it happens in the LAD and RCA territories.

Uh, And I'll just give you

here just like, uh,

before, we'll show the common areas where PA P patients, uh,

develop, uh, A VSD post mi.

It can be in the inferior septal, uh, area,

which in short axis will be this segment here,

number nine on the bullseye.

Number nine is here, your apical four chamber here,

or it could be in the, uh, anterior apical

area, which would be 14 here in the parasternal,

long axis 14 here in the, uh,

apical four chamber,

or in your course in the apical short axis view.

It'll be in this segment here.

So the use of color doppler is, is essential

to identify if this patient, uh, to identify the location

and if there is a left or right shunt.

And this is a, this case here is an example of a patient,

uh, where I missed.

They had a VSD.

I was doing this echo, uh,

in the unit on this particular patient.

And, uh, I had a fellow with me.

I was taught conversation with conversating with a fellow.

So I wasn't, uh, paying as close attention as I should.

So these are images, or, you know,

I'm showing you these views in the hindsight.

So if you look at the parasternal long axis view, there is

a dropout here.

There's a, also a, a kinetic segment here in the, uh,

apical, uh, section of the, uh, left ventricle.

And, uh, I didn't make my color box quite big enough.

If I would've, uh, noticed, noticed it, uh,

while doing the echo, I would've had it more apically placed

where you can see flow going in, in and out.

But even though I didn't,

you can still catch it a little bit here.

And here's the, uh, four chamber of view of this patient.

And you can see the a kinesis here

in the, uh, septal region.

And then this is where I saw the, uh,

VSD when I started doing my contrast images.

When I went to the three chamber,

I noticed this huge dropout here in the anterior

septal, uh, region.

And I was like, wow, this patient has A VSD.

And, uh, so that was determined,

even though I didn't recognize it before.

And here are some more contrast images.

You can really see it good here in the parasternal.

Long axis. Here you can see this dropout.

So they did a t on the patient,

and you can clearly see

drop out here in the anterior septal region.

And you can see the color flow, turbulent flow right there.

And here's another patient that, uh, same thing, same type

of VSD patients on the Impella.

Here, you can see this area of kinesis

using biplane.

I put the cursor here, uh,

and the, uh, in this segment of the heart, which allows me

to see the rupture in short axis.

So you can see here where the rupture is clearly

color flow Doppler showing the, uh,

left to right shunt.

And then with contrast, again, seeing the dropout here.

So also, uh, did a 3D, uh, acquisition of this patient.

And using 3D allows you, gives you a lot of information

about the, uh, the VSD.

Uh, you can see the shape of it.

You can, uh, you can, you can size it.

Uh, 'cause oftentimes with these, uh, VSDs, uh, they'll,

they'll try to do a, uh, plant place,

a amplatzer device, something that they do, uh,

in the cath lab with a catheter, as opposed

to taking 'em to, uh, to surgery.

And a lot of times it's, that's what they'll do.

And it's important for them to know how big it is,

so they'll know if, you know, the udder device,

uh, will fit at all.

So this is, uh, pretty much the, uh, end of my, uh,

presentation tonight.

Uh, hopefully you learn some new things

and some new techniques on how to assess patients.

Uh, for, especially for a pseudo aneurysm

or aneurysm, uh, it's, it's important

to utilize all the tools that you have, uh, in your lab.

Most of the machines now that they're, they're making,

you know, have 3D capabilities.

So if you're in a lab where you have a 3D probe, uh, put it

to use, uh, you know, use, use the biplane, use the 3D,

use whatever you know is at your disposal exposure to,

you know, assess, uh, uh, the, the heart to try

and determine if they have, uh, a v uh, a pseudo aneurysm

or an aneurysm.

Uh, definitely to use contrast.

Uh, someone told me that there are a lot,

most echo labs don't even use contrast ever,

or I don't know if most,

but many don't, which is very scary to me.

Contrast is a very powerful tool as well.

Use that, you know, especially if you, you know,

a patient has an aneurysm, you know,

how can you rule out thrombus?

How can you rule out pseudo aneurysm?

Uh, you know, these are very important, uh,

life-threatening things, uh, that we need to determine,

you know, if the patient has it, you know, be before they,

because we're normally, we're the first, one

of the first tests that's ordered for patients to assess.

And, uh, so we're, we're kinda like the, the gatekeepers to,

to make that determination, you know,

and based on the tests that we do determines on, determines

what steps are taken next.

So that's all I have for you tonight.

I thank you for, for joining me.

And if you have any, uh, questions

or comments, please let me know.

I will address any comment

or res question that you, uh, have,

just type it out in the chat box.

Okay? Thank you so much, Billy.

Thank you so much, Billy, for all this information.

I think it was great.

Uh, it's always good to know from cases,

uh, cases, studies about like new, uh,

encounters, discoveries that you can have

and how you, you are able to use it, uh,

when you are seeing a patient.

So thank you so much for the information. Billy.

Um, I wanna say everyone to everyone, hi,

uh, thank you for joining us today.

And there is a question here.

Um, so Billy, can you,

can you read the question?

Yes. Okay. So I have a question here.

It says, in the first case, would the outcome,

would the outcome have been different if the pseudo aneurysm

had been discovered first?

Um, possibly.

Um, I think that being that this patient was so,

such bad condition, um,

but I, I, I do think, uh, well, I, I think it, i, I think,

um, you know, determining of the pseudo aneurysm, uh,

played a role in them getting the, the heart transplant

as soon as they did.

Because, you know, the, the notes, you know,

after the cardiac MRI showed that this patient

did not have a pseudo aneurysm,

but a true aneurysm, you know,

then they weren't even considering surgery.

You know, they, they, well, I mean, really,

he didn't have much of a surgical option.

See, this patient had very few options.

Really, his only option, whether it's a pseudo

or true aneurysm, was a heart transplant, really, uh,

basically because, you know, he was in such bad condition.

Uh, but I think, I still think it's important

because it make, I think it just made them realize

that it is, uh, it's, it's already urgent,

but it's even more urgent than they probably, uh,

were thinking before, before,

because they were just kind of, you know,

because that's basically why they were doing the MRI,

they wanted to make sure, you know, that it,

that it was not a, uh, pseudo aneurysm.

And so that did play a role in their decision they played.

'cause if they would've known that earlier, like four months

before I did the echo, yes, it,

I think it would've made a big difference

because that patient, you know, is at risk

for setting rupture.

You know, they wouldn't have let four months go by without,

you know, trying to do something.

So, yeah. That's a very, very good question.

Um, thank you so much for the question.

And we have another one.

Uh, I think this is gonna be the last question,

and if you also Billy B one Okay, sure.

To add something else. Yeah.

We have another question. Uh, it says, in the case

of very low ejection fraction, is it possible

to check flow in the neck of the aneurysm?

Uh, very good question. Yeah, you can still check flow, uh,

in the neck of the aneurysm, uh,

but you won't get, you know, as high of a velocity.

Uh, you can check of course, you know, that's where,

where contrast can help.

You can see with a contrast.

But your doppler with signal will be of course,

uh, much weaker.

Um, and yeah.

And that, that does play a role in, in that, yes.

But that's why, you know, like I said, contrast

can, can help with that.

Okay. So thank you so much, Billy.

Thank you so much everyone for joining us today.

Uh, I wanna tell you, you are very welcome

to visit our website.

Uh, that is

WIA e.com.

You can check all our courses.

Uh, we have o ob, GYN, we have cardiology, we have

abdominal, we have echo, we have, um,

we have ergonomics, we have a head and neck.

We have a lot of categories

that I'm sure you're gonna be interested in.

Uh, so we invite everyone to join us.

Uh, remember, uh, this is July.

You have six months to earn credits.

So you are very welcome to our community.

Uh, Billy, thank you so much, uh, for all this information

and see you guys next month.

Mm-hmm.

MI Complications: Aneurysms & Ruptures

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