Life-saving Cardiac Ultrasound: different approaches, a

common goal

Goal-orientated echocardiography

Susanna Price MD PhD

Consultant Cardiologist & Intensivist
Royal Brompton Hospital, NHLI, Imperial College, London, UK
Conflict of interest?

• None
Critical Echocardiography: a new application?

• 44% of patients with a PAC in place have additional information from echo leading to change in therapy (Poelart, Chest
1995)

• Aetiology of unexplained hypotension revealed in 48% of MICU patients, leading to change in therapy (Heidenreich
1995)

• Focused echocardiography improves diagnostic accuracy and efficiency in the ER (Jones 2004)

• Universal definition of AMI includes echocardiography (ESC 2007)

• Pre-hospital emergency echocardiography changes therapy in 60-80% (Breitkreutz 2010)

• Resuscitation guidelines recommend the use of echocardiography in cardiac arrest (ILCOR 2010)
Potential scope of critical echocardiography
ER, ICU, anaesthesia ICU
Penetrating trauma, blunt trauma Systolic function and regional wall motion abnormalities
Postcardiotomy due to cardiac surgery Diastolic function
Hypotension, shock of unknown origin Hypovolemia and volume responsiveness
Unconsciousness, unresponsiveness Tamponade and pericardial disease
Acute severe dyspnoea The sepsis syndromes
Syncope in young adults Effects of pre-load and afterload and assessment of filling status
Vein thrombosis Acute cor pulmonale
Acute myocardial infarction (AMI)), mechanical complications of AMI Hypoxemia
Atypical chest pain: suspected aortic dissection, suspected aortic abdominal or Complications of acute MI
thoracic aneurysm, nontraumatic cardiac rupture Chest trauma
Iatrogenic complications because of invasive procedures (e.g. Insertion of an Assessment of shock
artificial pacemaker, pulmonary artery catheter, electrophysiologic Failure to wean from mechanical ventilation
investigative procedures) Hemodynamic measurements
Great vessel disease
Anaesthesia
Cardiac Arrest:
Cardiac surgery
Pulseless electrical activity
Intraoperative TOE and epicardial echocardiography
Suspected cardiac tamponade
Postoperative assessment on the ICU (TOE and TTE)
Early detection of ROSC
surgery-specific
Bradycardia-asystole, pacemaker-ECG
general
Performance of CPR
Non-cardiac surgery
Effectiveness of chest compressions
Intraoperative high-risk cases
Hypotension, adaptation of vasopressors
Systolic function and regional wall motion abnormalities
Hypovolemia and volume responsiveness
Effects of pre-load and afterload and assessment of filling status
Hemodynamic measurements
Why echocardiography in critically ill?

• Risks of transportation: AI 8-68% in critically ill

• 31% of AIs – significantly adverse outcome, 3% in cardiac arrest

• Avoidance of repeated irradiation (staff & patient)

• Immediately available, safe

Echocardiography in the critically ill - scope

a. Monitoring b. Physiology c. Perfusion d. Anatomy

Pitfalls
Imaging in the acute arena: an emerging specialty

• Awareness of critical care cardiology/acute cardiology – subspecialisation

• Imaging requirements are different:

• Point-of care imaging – by necessity/by choice (reduced risks)
• Avoidance of unnecessary radiography (patient and staff)
• Not single shot diagnostic – rather monitoring
• Time critical scenarios

• Emergence of recommendations in guidelines (ESC, AHA, ILCOR)

• Little possibility for integrated multimodality imaging in context of MDT review
• Increasing uptake by non-cardiologists

• High stakes environment

Life-saving Cardiac Ultrasound: different
approaches, a common goal

Goal-orientated echocardiography
Clinical cases: echo studies undertaken in my ICU yesterday
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis, EF now normal on inotropic infusion: should we add ivIG or cyclophosphamide or wait?
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old HF arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – low CO state: does he need MCS, and which?
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old HF arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
RV tIVT 15, LVtIVT 8, L-VTI 6, PASP 15mmHg, PAT 82msec
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function: is there a right heart component to this and what can I do to resolve?
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old HF arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
CI 7.8, PASP 52mmHg, CVP +21, milrinone 0.4mcg/kg/min, BiPAP 12+14, FIO2 0.8, saturations 88%
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO: are we sure the goals of ECMO are met?
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old HF arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty: haemorrhage from ETT – why?
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old HF arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Clinical cases: my ICU patients yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation: cannula vs beta blockade?
7. 45 year old PH transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old PH transferred for ongoing therapies, cardiogenic shock: ?options ?improved
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Pulmonary TAPSE

Maximal pulmonary vasodilatation

• iNO
+ Levosimendan
+ Nebulised prostacyclin
+ Low dose vasopressin
+ Nebulised milrinone

Speaker
Clinical cases: my ICU yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old PH arrested and transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Tei index: [580-200]/200 = 1.9
ET: 0.2x104=20.8sec/min, FT: 0.18x104=18.9 sec/min
tIVT: 60-(20.8+18.72) = 20.2 sec/min
Mitral Aortic

Mitral Aortic
Clinical cases: my ICU patients yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old PH transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
Biomedical engineer Patient
Clinical cases: my ICU patients yesterday

1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s
thyroiditis
2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction
3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic
function
4. 42 year-old man post-PCI supported with peripheral VA-ECMO
5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT
6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation
7. 45 year old PH transferred for ongoing therapies
8. 59 year-old, ischaemic cardiomyopathy, arrested post-start of ICD implantation
9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery
10.18 year-old Influenza B unable to wean off sweep from VV-ECMO: lungs or cannula or heart?
ABGs
Key questions?
“The real benefit to the patient [of echocardiography] is not the technical
skill, but rather the application of intellectual input…. information,
communication and teamwork are essential”

Jos Roelandt, 1993

Key questions

• What is the clinical context?

• What do the intensivists really want to know?
• What’s the underlying diagnosis?
• How is the patient being sedated/ventilated/supported?
? • What is limiting the cardiac output/elevating the venous pressure?
• Is the left atrial pressure elevated?
• Is the heart rate/AV delay/VV delay appropriate?
• Is there any other relevant information?

• be systematic
• always look for the reversible
What does the cardiology literature say?

“from an ethical point of view, emergency echo should be

performed by anyone who is adequately trained….
with the necessary knowledge used thoughtfully, correctly and
with care” (EACVI, 2014)

“ It is strongly recommended that all cardiologists….complete an

additional training programme consisting in
interpreting/reporting….echocardiographic examinations in critical or
life-saving scenarios, in order to further improve technical skills and
build experience….For non-cardiologists the requirements are
essentially the same” (ESC EACVI/ACCA, 2015)

Lancellotti P, Price S, Edvardsen T et al.,

Eur Heart J Cardiovasc Imaging. 2015 Feb;16(2):119-46
Don’t be fooled…

• Not “simplified” echocardiography

• Full range of applications and techniques may be needed
• Difficult circumstances
• Life-changing decisions

• Targeted to what the patient and treating clinician need to be known in

order to save life
Lessons from elsewhere?
Take-home messages

a. Know what questions to ask

b. If the imaging is suboptimal, don’t guess

c. If you don’t understand what the intensivists are telling you, ask

d. Phone a friend/ask for help – these are the sickest patients in the hospital
Life-saving Cardiac Ultrasound: different approaches, a
common goal

Goal-orientated echocardiography

Thank you