UNIT 2 ECHOCARDIOGRAPHY IN

ISCHAEMIC HEART DISEASE 1

Structure
2.0 Objectives
2.1 Introduction I
I
2.2 Assessment of Regional Wall Motion Abnormality I

2.3 Global LV Systolic and Diastolic Functions 1

' 2.4
2.5
Detection of Complications of MI
Let Us Sum Up
i
2.6 Answers to Check Your Progress

2.0 OBJECTIVES
After going through this unit, you should be able to:
evaluate a patient of chest pain for Regional wall motion abnormality, define
various segments;
describe about wall motion score index;
assess LV function;
describe the status of diastolic function; and
recognise mechanical complications like acute MR, VSD, and whether LV
I:
thrombus is present or not.

2.1 INTRODUCTION
Echocardiography has become an established and powerful tool for diagnosing
presence of CAD and defining its consequence. It can help in early detection of
acute myocardial infarction (even in the absence of typical electrocardiographic
evidence), evaluation of RWMA, detection of post-infarction mechanical and
functional complications. Stress echocardiography is useful for evaluating the
presence, location and severity of inducible myocardial ischaemia, as well as for
risk stratification and prognostication.

Fig. 2.1: Echocardiography for chest pain evaluation

 When a patient presents to the emergency room with chest pain, early diagnosis Echocardiography in
is warranted to provide appropriate therapy to the patient. Most important is to Lscbaemic Heart Disease
know whether pain is ischemic or non-ischemic. Here lies the role of
echocardiography, besides the use to cardiac enzymes to diagnose acute coronary
syndrome. Echocardiography provides the greatest amount of incremental
information when the clinical history and ECG findings are non-diagnostic.
~chocardiograph~ also helps in identifying non-ischaemic cause for chest pain
such as pericarditis, aortic dissection, pulmonary infarction aortic stenosis or
regurgitation.
What to look for in patients of IHD?
I ) Regional wall motion abnormality

2) Global LV systolic and diastolic functions

3) Assessment of complications

2.2 ASSESSMENT OF REGIONAL WALL MOTION

ABNORMALITY
A critical occlusion of a coronary artery leads to myocardial ischemia which is
manifested as regional wall motion abnormality (Abnormal motion and loss of
systolic thickening) where is readily identified by 2D echocardiography.
Decreased or cessation of myocardial contractility (systolic thickening) to the
immediate manifestation of myocardial ischaemia, even before occurrence of ST
changes or development of symptoms. Normally LV free wall thickness increases
more than 1.5 times of the diastolic dimensions during systole. Ischemic muscle
shows 3 discrete patterns of movement.

1) Hypokinesis: When the muscle shows systolic inward motion, however the
amplitude of movement is less as compared to normal adjoining areas i.e.
I
systolic wall thickness 1.2-1.5 times the diastolic thickness.

2) Akinesis: When the muscle shows no perceptible systolic motion and

systolic thickness is less than 1.1 times the diastolic dimensions.

3) Dyskinesis: Dyskinesis is defined as a myocardial segment moving'outward -

during systole, usually in association with systolic wall thinning.
In order to assess the wall motion, we have to concentrate on not only the
movement of muscle but also the thickening during systole. This increases the
specificity of wall motion study considerably.
Limitations
Inadequate visualization of the endocardium (may be present in 10-20 per cent of
cases).
However, improved equipment, better transducer designs and imaging on digital
platform have improved the visualization of the endocardium to a large extent.
Quantitative Analysis of Regional Wall Motions
Various attempts have been made in the past to try and quantify the ischaemic
myocardium, however till date the best and most widely used is the 16 segment
Fundamentals of scoring system, which has also been approved by American society of
Echocardiography Echocardiography. The system was devised keeping in mind the common pattern
of coronary blood supply. The whole of the left ventricle muscle is divided into
16 segments, which can be visualized in the conventional views. The whole
length of the LV is divided into 3 segments. The apical, mid segment and basal
segment. The circbmference of basal and mid myocardium is divided into 6
segments-Anterior Segment, Anterior wall, lateral wall, posterior wall, inferior
wall and septum. Tbe apical portion however lacks anterior septum and posterior
wall. (Fig. 2.2)

Ant. S e ~ t u m Ant. Septum

inferior Posterior

Basal Segments Mid Segments

at the Tips of Mitral Valve at Papillary Muscle Level

Septum ,- Anterior

lnferidiL";Lateral
Distal Segments
at the Level of Apex

Fig. 2.2: Schematic depresentation of LV divided into 16 segments in short axis

view at 3 leivels-basal, mid and apical

If the translate thesd segments into other conventional views, we find that
parasternal long axiq view shows anterior septum and posterior wall, apical 4
chamber view show$ septum and lateral wall and apical 1 chamber view shows
inferior and anterior;wall. (Fig. 2.3)

Ant. S e ~ t u m
Anterior
Ant. Sdptum

Posteiior Wall
MID Segments
Plak View at Papillary Muscle Level

Septu

Apicdl 4 C View
1
I
I
1 I
Apical 2 C View

Fig. 2.3: Schematic reI)resentation of four conventional views showing various walls
visualized in different views
With variable degree of overlap the segments marked above denote coronary Echocardiography in
Ischaemic Heart Disease
artery temtory. These can be plotted on a Bull's eye plot, which gives a better
appreciation of the segments and the regions involved. (Fig. 2.4)

Anterior

A
Anterior
Septum

Fig. 2.4: Bulls eye plot showing overlap of various segments and blood supply by
different coronary arteries

Each segment is assigned a score based on its contractility as assessed visually:

Normal- 1
Hypokinesis-2

On the basis of this wall motion analysis scheme, wall motion score index
(WMSI) is calculated to semi-quantitate the extent of regional wall motion
abnormalities.

WMSI =
Sum of wall motion scores
Number of segment visualized

Normally contracting LV has a WMSI of 1 (each 16 segment receive a wall

motion score of 1, hence total score of 16 and WMSI = 16/16 = 1).

Score is higher with larger infarcts, wall motion abnormalities become more
severe.
Patients with WMSI greater than 1.7 had a perfusion defect greater than 20 per
cent. (Fig. 2.5)
Fundamentals 'of
Echocardiography
. -... .- .

1 1:
i WMSI
! % Normal 100

I
X-Cannot Interpret
4-Dyskinetic
0-Hyperdynamic
5-Aneurysmal
1 -Noqknal
6-Akinetic wlscar
2-Hypokinetic
7-Dyskinetic wlscar
3-Akinetic
I
Fig. 2.5: Wall motion score index

2.3 GLOBAL LV SYSTOLIC AND DIASTOLIC

FUNCllZONS
It is clear from thd literature that LV dysfunction is an independent determinant
of the prognosis id patients with ischemic heart disease. Several parameters can
be measured for Jsessment of LV systolic function.
1) M-Mode Echlocardiography
With the cursor-beam cutting the left ventricle just beyond the tips of mitral
valve in an adequate parasternal long axis view, the M-Mode shows the left
ventricular We wall and septa1 thickness in systole and diastole. The LV

4
systolic and iastolic dimensions can be measured and following parameters
can be calcul ted
LVED-LVES x 100
Fractional Shbrtening (FS) = ,

LVED
 LVED-Left ventricular end diastolic dimensions Echocardiography in
Ischaemic Heart Disease
LVES-Left ventricular end systolic dimensions
Normal value = 28-44 per cent
This describes the systolic function at base of the heart. In absence of regional
wall motion abnormalities, this may reflect rest of the left ventricle. This is
usually calculated automatically from online software using M-Mode ventricular
dimensions in systolic and diastolic
Ejection Fraction = 2x fraction shortening provided there .are no RWMA.
2) Two Dimensional Echocardiography
I) Eye Balling
Two-dimensional echocardiography provides a good visual perception of
cardiac functions. With experience, the echocardiologist learns to
perceive and approximate the LV ejection fraction visually. This is
called Eye Balling. Whenever this method is used, a value to the nearest
10 per cent or a range (e.g. 40-50 per cent) should be given since
estimate can never be precise.
11) Modified Simpson s' Method
This is the commonest method available for objective calculation of left
ventricular volumes, which can be computed to obtain LV ejection
fraction. In modified Simpson's method LV is traced in diastole and
systole in apical 4 chamber and two chamber views. LV is cut along its
long axis into 20 cross sections.
LV volume = 7c/4 (a1 x bl) x Ll20
a' = diameter of LV in apical 4 L view
b1 = diameter of LV in apical 2 L view
All present day echocardiography machines have built in software for calculation
of LV volumes and ejection fraction by modified Simpson's method. The
echocardiogram can be manually traced offline during diastole and systole and
the machine automatically gives LV volumes and ejection fraction. For accuracy
of above method the mandatory requirement is adequate endocardia1
visualization. This method is operator dependent and depends on operator's
experience. [Fig. 2.6 (a) and (b)]

Fig. 2.6 (a): LV in diastole Fig. 2.6 (b): LV in systole

Fundamentals of Two Dimensional ech~cardiographicimage demonstrating calculation of LV
Echocardiography volumes by modified simpson's method
Assessment of Diastdlic Function
Myocardial ischemia Clters diastolic function of left ventricle. The earliest
abnormality to appear with prolonged ischemia is delayed myocardial relaxation
i.e. A > E., increased deceleration time. Diastolic function after myocardial
infarction (MI) depends upon the interaction of various factors:
a Ventricular compliance
a LA pressure
a Loading conditioos
a Heart rate
a ' Medications
Patients with severe LV dysfunction after MI demonstrate restrictive filling
pattern i.e. E >>> A and decreased deceleration time. Patients with restrictive
transmitral filling pattlern most likely experience heart failure. Basics of diastolic
dysfunction are explained in subsequent section. [Fig.2.7 (a) and (b)]

Fig. 2.7 (a): Pulse wave Doppler across mitral inflow Fig. 2.7 (b): Restrictive MV inflow pattern E >> A, DT
showing diastolic relaxation impairment A < 160 msec
>E

Direct Visualisation o f Coronary Arteries

Coronary arteries cad be directly visualized using two-dimensional
echocardiography, especially in patients with good window. The commonest
artery to be seen is the left main, proximal LAD and LCx in the SAX view the
level of aortic valve. RCA and LCx can be seen in the AV groove using apical
window. The arteries are not visualized as a continuous channel, they are seen in
small portions in diaerent phases of cardiac cycle. The visualization is better on
Transesophageal echocardiography.
 Echocardiography in
Ischaemic Heart Disease

2;4 DETECTION OF COMPLICATIONS OF MI

Many life threatening complications can follow myocardial infarction.
Development of these complications may necessitate urgent intervention or
change in therapy for the survival of the patients. A carefully done
echocardiographic examination can help in early detection of these complication.
Infarct Extension: Serial echocardiogram showing increase in the number of
segments showing wall motion defect or decrease in segments functioning
normally would indicate infarct extension, and merits urgent intervention. (Fig.
2.8).

Fig. 2.8: Two-dimensional echocardiography of patient with anteroseptal

myocardial infarction showing akinetic thinned out interventricular
septum and apex
Fundamentals of Infarct Expansion: lbfarct expansion usually occurs in segments which are
Echocardiography akinetic or dyskinetid. The number of infiacted segments remain the same,
however, there is inct-ease in segmental or global circumference of the left
ventricle on serial echocardiography. The segments become thinned out and
expand. This is the biasis of ventricular reimodeling which impairs prognosis and
function by increasing myocardial wall stress and tension and consequently
oxygen demand. The remodeling can be prevented by ACE inhibitors and other
afterload reducing agents. I
Ventricular AneurysM: Anterior infarcts are more commonly found to form
ventricular aneurysms. These can be detected as outpouching of a particular
1
segment producing deformed LV contour during diastole, which gets worsened
during systole. The aneurysm besides being arrhythmogenic, is potential source
of thrombus formation due to blood stasis. It can also lead to reduction in
forward cardiac o u w t as the aneurysm accommodates a portion of it. Aneurysm
is the end result of ibfarct expansion.
Kntricular Pseudoalneurysm: This is coinmoner in posterior infarcts. The
characteristic finding is a breach in the continuity of the myocardium with an
outpouching lined bp the pericardium. [Fig. 2.9 (a) and (b)] Colour Doppler can
show flow in and out of the pseudoaneurysm. The genesis is as a result of
myocardial perforation which is walled off by pericardium. The perforation may
lead to cardiac rupture, tamponade and death. Thus urgent surgical correction is
required.

Fig. 2.9 (a): Four chamber view. Fig. 2.9 (b): Two chamber view showing apical
pseudoaneurysm with large
thrombus

Two-dimensional echocardiography of a patient with anteroseptal myocardial

infarction

kntricular Septa1 Pefect: This is another dreaded complication of myocardial

infarction, which can be fatal unless surgically managed. The usual site of VSD
is the junction of abnetic of dyskinetic area (infiacted territory) with a
hyperkinetic area (donna1 territory). This is the place we should look for a VSD
on echocardiograpby. Further more turbulent systolic color flow from left
ventricle into the right ventricle through the defect clinches the diagnosis. The
important thing to note is that unconventional views may be required to highlight
the defect. [Fig. 2.10 (a) and (b)].
 Echuca~rdiographyin
Ischaemic Heart Disease

Fig. 2.10 (a): Plax view-showing left to right Fig. 2.10 0):
Zoom view of septum in apical
flow across septum (VSD) in a view showing flow across VSD
patient with anterior wall
myocardial infarction

Mitral Regurgitation: Significant mitral regurgitation may result from papillary

muscle rupture due to infarction. The echocardiogram shows flail mitral leaflets
with evidence of papillary muscle rupture, there is systolic noncoaptation, and
mitral tips pointing towards the left atrium with significant MR on colour
Doppler. (Fig. 2.11)

Fig. 2.11: Two-dimensional echocardiography with colour Doppler in a patient with

inferior wall myocardial infarction. Apical four-chamber view shows
mitral regurgitation

The MR jet continuous wave trace shows early deceleration indicating high LA
pressures. In cases with difficult window transesophageal echo may be helpful in
the diagnosis.
Other causes of mitral regurgitation may be ischemia which leads to systolic non
coaptation with leaflet pointing toward LV side. This may appear on stress and
get relieved with rest on stress echocardiogram. The papillary muscles may be
thick scarred and calcific as a result of healed infarction. This may lead to
significant MR.
Fundamentals of Mural Thrombi: The thrombi are seen as echogenous mass fixed or mobile
Echocardiography usually at or adjacent to a dyskinetic or akinetic area, which is commonly
aneurysmally dilated. 1 [Fig. 2.12 (a) and (b)] Echocardiography is supposed to be
a gold standard for dktection of thrombi.

Fig. 2.12 (a): PIax view-large mural thrombus attached tb Fig. 2.12 (b): Apical four chamber view showing large
anterior septum thrombus attached to akinetic apex

(Two-dimensional edhocardiography in a patient with large anteroseptal

myocardial infarctiop)
Thrombi usually ocdur at the apex following anterior wall infarction. The trick to
find thrombi is to tdoroughly evaluate the dyskinetic, akinetic and aneurysmal
areas by convention81 and unconventional views using a high resolution, high
frequency i.e. 5 Mega Hz transducer.
Right Ventricular Iktfarct: This is commonly associated with inferior wall
infarction and is cotbmonly missed until a high index of suspicion is maintained
on clinical and elecl/rocardiographic grounds. The echo shows dilated and
hypokinetic RV in dddition to inferior wall motion defects. The criteria may be
important specially iwhen the EKG changes, which are usually transient, settle
down.
 Echocardiography in
2.5 LET US SUM UP Ischaemic Heart Disease

~chocardiographyis a non-invasive, portable and easily accessible technique

which helps in comprehensive assessment of cardiac morphology, hemodynamics
and functions in real time. The added advantage of immediate availability of the
results has immense value during the management of a patient with ischemic
heart disease. It helps in early detection and diagnosis of the disease, in
assessment of its effect on cardiac haemodynamics and detection of related life
threatening complications.
Besides helping in diagnosis, echocardiography provides prognostic information
which helps in deciding right type and time of therapy for the patient.
Echocardiography has presently become a mandatory investigation for evaluation
C
of patients with CAD.

2.6 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Normal wall thickness increases more than 1.5 times of diastolic dimensions
during systole.

2) Dyskinetic movement is when myocardial segments move out of range in

systole i.e. it moves outwards when other segments are moving inwards
during systole. This occurs in association with systolic thinning.
Check Your Progress 2

1) For taking LV dimensions in M -Mode cursor beam should be just beyond

the tips of mitral leaflets in PLAX view

2) The earliest abnormality to appear with prolonged ischemia is delayed LV

relaxation that is a>e (grade I diastolic relaxation impairment)
Check Your Progress 3

S.No Aneurysm Pseudoaneurysm

a) Out pouching & thinning of Breach in continuity of

particular segments myocardium with an outpounching
lined by pericardium

b) End result of infarct expansion End result of myocardial

perforation

c) Wide neck Narrow neck

d) Common with anterior wall MI Common with inferior wall MI

Leads to thrombus formation, Lead to cardiac rupture, tamponade

reduction in forward cardiac output deaths

f) Treatrnent-conservative / surgical Urgent surgical correction