1. Enfermedad Arterial Coronaria Dr. Armando Polanco Departamento de Ecocardiografia

4. Enfermedad Arterial Coronaria FIGURE 15.1 . Anatomic rendering of a short-axis view of the left ventricle in diastole (top) and systole (bottom) . Note the circular geometry of the left ventricle in both diastole and systole and the crescent-shaped geometry of the right ventricle. In the real-time image, note the symmetric wall thickening and inward endocardial excursion. The location of the major epicardial coronary arteries is also shown. (Graphics by Amanda Almon and Travis Vermile)

5. Enfermedad Arterial Coronaria FIGURE 15.2 . Parasternal short-axis view of the left ventricle ( LV ) at the papillary muscle level. As with the accompanying schematic (Fig. 15.1), note the circular geometry of the left ventricle and the symmetric endocardial inward motion and wall thickening from diastole (A) to systole (B) . RV, right ventricle.

6. Enfermedad Arterial Coronaria FIGURE 15.6 . Anatomic rendering in diastole (top) and systole (bottom) of ischemia or myocardial infarction in the distribution of the left anterior descending coronary artery. When comparing diastole and systole, note the lack of thickening in the anterior wall and anterior septum compared with normal hyperdynamic motion in the uninvolved segments. (Graphics by Amanda Almon and Travis Vermile)

7. Enfermedad Arterial Coronaria FIGURE 15.7 . Parasternal short-axis view recorded in diastole (A) and in systole (B) in a patient with acute left anterior descending coronary artery occlusion and myocardial infarction. B: Note the lack of wall thickening and the dyskinesis of the anterior septum ( outward-pointing arrows ) and the normal motion of the posterior wall ( inward-pointing arrows ). LV, left ventricle; RV, right ventricle.

8. Aneurisma Ventricular FIGURE 15.8 . Anatomic rendering in the four-chamber view depicts a left ventricular apical aneurysm. Left: Diastole. Right: Systole. Note in diastole the abnormal geometry of the apex with localized apical and septal dilation and the relative thinning of the wall compared with the thickness in the proximal walls. Right: The preserved thickening of the proximal walls and a lack of thickening in the aneurysmal segment in all segments distal to the arrows are shown. This abnormal geometry in both diastole and systole with wall thinning is the hallmark of true ventricular aneurysm. LA, left atrium; RA, right atrium. (Graphics by Amanda Almon and Travis Vermile)

13. Enfermedad Arterial Coronaria FIGURE 15.14 .Apical four-chamber views recorded in a normal ventricle in diastole (A) and systole (B). Note the normal bullet-shaped geometry of the left ventricle that tapers at the apex and the symmetric contraction of all visualized walls. Note also the stable position of the apex in the real-time image, indicating that the transducer is at the true apex. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

17. Infarto Agudo al Miocardio FIGURE 15.20 . Parasternal long-axis echocardiogram recorded in a patient with extensive anteroapical and anterior wall myocardial infarction. Figures 15.20 through 15.23 are recorded in the same patient. A: In the parasternal long-axis view, note the normal geometry of the left ventricle ( LV ) in diastole. B: In systole, note the normal motion of the proximal inferior wall and a lack of thickening and akinesis of the entire anterior septum (arrows). Incidental note is made of a pleural effusion ( Pleff ). Ao, aorta; LA, left atrium; LV, left ventricle.

19. Infarto Agudo al Miocardio FIGURE 15.21 . Parasternal short-axis view recorded in the same patient depicted in Figure 15.20. Note preserved circular geometry of the left ventricle ( LV ) in diastole (A) and the normal myocardial thickening and endocardial excursion of the posterior wall. B: Recorded in systole, the anterior and mid septum are both full thickness but dyskinetic ( arrows ). RV, right ventricle.

20. Infarto Agudo al Miocardio FIGURE 15.22 . Apical two-chamber view recorded in diastole (A) and systole (B) in the patient previously presented with extensive left anterior descending coronary artery territory myocardial infarction. In the two-chamber view, note the preserved function of the proximal 50% of the inferior wall and the akinesis or dyskinesis of the distal inferior wall, apex, and anterior wall (arrows) . In this example, the involvement of the distal inferior wall is due to a wraparound left anterior descending coronary artery and not the result of concurrent ischemia in the right coronary artery. LA, left atrium; LV, left ventricle.

21. Infarto Agudo al Miocardio FIGURE 15.23 . Apical four-chamber view recorded in the same patient depicted in the three previous figures. In the four-chamber view, note the abnormal geometry of the distal septum ( area between the two arrows ) present in diastole (A) . B: In systole, function is preserved at the base of the heart ( inward-pointing arrows ) with akinesis or dyskinesis in the distal half of the left ventricle ( outward-pointing arrows ). Incidental note is also made of an atrial septal aneurysm [ arrow in the left atrium ( LA )]. Note the bowing of the atrial septum from left to right, implying elevated left atrial pressure, presumably secondary to left ventricular dysfunction. LV, left ventricle, RA, right atrium; RV, right ventricle.

22. Infarto Agudo al Miocardio FIGURE 15.24 . Parasternal short-axis view recorded in a patient with a classic inferior wall myocardial infarction. A: Recorded in diastole. Note the normal shape of the left ventricle ( LV ) in diastole. In systole (B) , the true inferior wall is thin and frankly dyskinetic ( arrows ), whereas the remaining walls contract normally. RV< right ventricle.

23. Infarto Agudo al Miocardio FIGURE 15.25 . Apical two-chamber view recorded in diastole (A) and systole (B) in a patient with an inferior myocardial infarction. In systole (B) , note the normal motion of the anterior wall and the frank dyskinesis of the proximal two-thirds of the inferior wall ( arrows ). LA, left atrium; LV, left ventricle.

24. Infarto Agudo al Miocardio FIGURE 15.26 . Apical four-chamber view recorded in the same patient depicted in Figure 15.25 in diastole (A) and systole (B) . Note the dyskinesis of the proximal 25% of the ventricular septum, which in this instance is attributable to septal involvement by the inferior myocardial infarction. Caution is advised when interpreting a wall motion abnormality in this location. The proximal ventricular septum in the apical four-chamber view often has abnormal motion. Only when the abnormality is seen in association with concurrent inferior wall myocardial infarction should it be presumed to be infarct as well. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

25. Infarto Agudo al Miocardio FIGURE 15.28A . Echocardiograms recorded in two patients with remote myocardial infarctions. Left: Apical long-axis views recorded in diastole (A) and systole (B) in a patient with an inferior myocardial infarction attributed to disease of the left circumflex coronary artery. Note in systole that the proximal two-thirds of the inferoposterior wall are dyskinetic and there is normal contraction of the anterior septum and apex. Right: Parasternal long-axis views recorded in a patient with a remote inferior/inferolateral myocardial infarction. Image at the top (B) , was recorded in diastole; note that the proximal one-third of the inferior wall is pathologically thinned with a dense echo signature consistent with scar. In the image at the bottom (C) , there is normal contraction of the anterior septum and more distal portions of the inferoposterior wall with akinesis of the infarct area ( downward-pointing arrows ). LA, left atrium; LV, left ventricle.

26. Infarto Agudo al Miocardio FIGURE 15.30 . Parasternal long-axis echocardiogram recorded in a patient presenting with an acute myocardial infarction and left bundle branch block. Note from diastole (A) to systole (B) , only the very proximal portion of the anterior septum has moved downward ( long arrow ) and the more distal portions of the septum are dyskinetic ( upward-pointing arrows ). This pattern should be easily distinguished from the wall motion abnormality seen in left bundle branch block. Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.

27. Infarto Agudo al Miocardio FIGURE 15.31 . Apical four-chamber view recorded in a patient presenting with a non---ST-segment elevation myocardial infarction. In this instance, only ST-segment depression with T-wave inversion was noted on the electrocardiogram, maximally in the anterior precordium. A was recorded in diastole. B: Note the fairly extensive area of dyskinesis in the distal septum and apex (arrows) . The wall motion abnormality noted here is virtually identical to that seen with typical ST-segment elevation or Q-wave myocardial infarction. LA, left atrium; LV, left ventricle, RA, right atrium; RV, right ventricle.

29. Infarto Agudo al Miocardio FIGURE 15.32AB . Parasternal long-axis echocardiogram recorded in a patient at the time of presentation with an impending anterior ST-segment elevation myocardial infarction (A, B) . C,D: The same patient on a follow-up echocardiogram recorded several days after successful reperfusion therapy. For each set of images, the end-diastolic frames are on the left and end-systolic on the right. At the time of acute presentation, note preserved motion of the proximal anterior septum ( downward-pointing arrow ) with dyskinesis of the distal septum (upward-pointing arrows) . D: Recorded in systole after reperfusion therapy and recovery of function; note the normal motion of both the anterior septum and inferoposterior walls.

30. Infarto Agudo al Miocardio FIGURE 15.33AB . Apical four-chamber views recorded in a patient presenting with extensive LAD distribution myocardial infarction. A, B: Recorded at the time of presentation; C, D: recorded approximately 3 months later after successful reperfusion therapy. For each set of images, diastole is on the left and systole on the right. Note the extensive wall motion abnormalities at the time of presentation with the acute event and near complete recovery of function 3 months later, with only a limited residual apical wall motion abnormality. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

37. Infarto Agudo al Miocardio FIGURE 15.38 . Apical four-chamber view recorded 36 hours after presentation with an extensive anteroapical ST-segment elevation myocardial infarction. A: Note in the image recorded in diastole that there is already abnormal left ventricular geometry with regional dilation of the distal septum (begins at arrow ). This is more apparent in the image recorded in systole (B) where there is akinesis and dyskinesis of the distal septum and lateral walls (distal to the arrows ). Because of the regional dilation, there is an obligatory thinning of the necrotic myocardium due to infarct expansion. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

40. Infarto Agudo al Miocardio y Formacion de Trombos FIGURE 15.39 . Apical four-chamber view recorded in a patient with an acute anterior apical myocardial infarction and early thrombus formation. Note the regional dilation of the left ventricle at the apex and the pedunculated, multilobulated mass protruding into the cavity of the left ventricle ( LV ) ( arrows ). RV, right ventricle.

42. Infarto Agudo al Miocardio FIGURE 15.40 . Subcostal view recorded in a patient with a limited inferior myocardial infarction and concurrent right ventricular infarction. A: Recorded in diastole. Note the dilated right ventricular cavity with relatively preserved right ventricular shape. B: Recorded in systole. Note the normal inward motion of the proximal right ventricular wall ( downward-pointing arrows ) and the dyskinesis of the apical portion of the right ventricular wall ( upward-pointing arrow ). LV, left ventricle; RV, right ventricle.

43. Infarto Agudo al Miocardio del VD FIGURE 15.41 . Off-axis four-chamber view recorded in a patient with an inferior myocardial infarction and right ventricular infarction. Note the dilation of the right ventricular cavity and the marked reduction in systolic function in the real-time image. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

44. Infarto Agudo al Miocardio del VD FIGURE 15.42A . Apical four-chamber view recorded in the same patient depicted in Figure 15.41 with an inferior myocardial infarction complicated by right ventricular infarction. In this instance, marked arterial desaturation was noted. A: Note the marked dilation of the right ventricle ( RV ) and right atrium ( RA ). B: Image recorded after injection of intravenous saline shows marked opacification of the right ventricle with a substantial contrast effect in the left ventricle ( LV ) and left atrium ( LA ), indicative of a pathologic right to left shunt, subsequently documented to be due to a large patent foramen ovale.

45. Infarto Agudo al Miocardio del VD FIGURE 15.44 . Apical four-chamber view recorded in the same patient depicted in Figure 15.43. A: Note the break in the continuity of the posterolateral papillary muscle with two portions of the papillary muscle head ( arrows ). B: Recorded in systole. Note the marked buckling of the mitral valve leaflet into the left atrium ( LA ) ( upward-pointing arrow ) and the ruptured papillary muscle base in the cavity of the left ventricle ( horizontal arrow ). LV, ventricle; RA, right atrium; RV, right ventricle.

49. IAM e Insuficiencia Mitral Severa FIGURE 15.45 . Transesophageal echocardiogram recorded in a longitudinal plane in a patient with inferior myocardial infarction and acute severe mitral regurgitation. This frame was recorded in systole, and a large portion of the papillary muscle head can be seen prolapsing into the left atrium ( LA ) ( arrows ). Ao, aorta; LV, left ventricle.

50. IAM e Insuficiencia Mitral Severa FIGURE 15.46A . Parasternal long-axis view recorded in a patient with functional mitral regurgitation due to myocardial ischemia and subsequent malcoaptation of the mitral valve. A: Image recorded in end-systole demonstrates tethering of the mitral valve toward the apex. The dashed line denotes the plane of the mitral anulus. Note the ``tenting’’ of the mitral leaflets into the cavity of the left ventricle. B: Image recorded in the same patient with color Doppler flow imaging reveals severe mitral regurgitation. In this instance, there is no anatomic disruption of the mitral valve apparatus and mitral regurgitation is due to functional abnormalities of mitral valve closure rather than an anatomic defect of the valve itself. The schematics denote normal (A) and abnormal (B) coaptation patterns for comparison.

51. IAM y Ruptura del Septum FIGURE 15.47A . A: Parasternal short-axis view recorded in a patient with an extensive inferior and inferoseptal myocardial infarction with a partial rupture of the septum. Note the very thin-walled aneurysmal tissue extending from the inferior septum ( downward-pointing arrow ) and a relatively narrow entrance ( leftward-pointing arrows ). B: Note the color flow signal demonstrating marked turbulent flow from the cavity of the left ventricle ( LV ) into the pseudoaneurysm and subsequently into the right ventricular cavity. RA, right atrium.

52. IAM y Ruptura del Septum FIGURE 15.48A . Apical four-chamber view recorded in a patient with acute inferoseptal and inferior myocardial infarction. Note the distinct break in the septal contour ( arrow ) (A) and the color flow signal traversing this ventricular septal defect ( arrow ) (B) . LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

56. ETE en Ruptura del Septum Post-IAM FIGURE 15.49 . Transesophageal echocardiogram recorded in a transverse plane (0 degrees) in a patient with a ventricular septal defect after acute myocardial infarction. Note the turbulent color flow signal traversing the ventricular septum through the large ventricular septal defect. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

57. Aneurisma Apical FIGURE 15.50A . A: Apical four-chamber views recorded in a patient with a very large chronic anteroapical myocardial infarction and apical aneurysm. Note the normal thickness of the proximal 50% of the left ventricle ( LV ) with marked aneurysmal dilation, abnormal geometry, and wall thinning in the distal half of the ventricle. Note also in the two-chamber view (B) the involvement of the distal inferior wall with a distinct break in function and wall thickness ( arrows ). LA, left atrium; RA, right atrium; RV, right ventricle.

58. Aneurisma Apical FIGURE 15.51 . Apical four-chamber view recorded in a patient with a smaller apical aneurysm. A: Image recorded in diastole; note the loss of the normal tapering of the left ventricular apex. B: Image recorded in systole in which the abnormal geometry, and the distinct break between the normally functioning basal two-thirds of the ventricle and the aneurysm, is more apparent.

59. IM Remoto Inferior y Aneurisma Basal FIGURE 15.53 . Apical two-chamber view recorded in diastole (A) and systole (B) in a patient with a remote inferior myocardial infarction and inferior aneurysm at the base of the heart. A: Recorded in diastole, note the abnormal geometry of the proximal inferior wall ( arrows ) ( INF ). This abnormality is even more prominent in the image recorded in systole (B) in which one can appreciate the preserved contractility of the distal inferior wall and anterior wall ( ANT ).

60. Aneurisma Basal FIGURE 15.54 . Apical two-chamber view recorded in a patient with a remote inferior myocardial infarction and a discrete basal aneurysm. In this instance, the outer wall of the aneurysm is noted by the upward- pointing arrows . Note the relatively narrow neck to the aneurysm and a laminar thrombus ( downward-pointing arrow ). In examples such as this, it may be difficult to separate a true aneurysm from a pseudoaneurysm. ANT, anterior wall; INF, inferior wall; LA, left atrium; LV, left ventricle.

61. Aneurisma Anteroapical FIGURE 15.55A . Apical four-chamber view recorded in a patient with an anteroapical aneurysm who subsequently underwent a Dor myoplasty for left ventricular remodeling. A: The preoperative image shows a large anteroapical aneurysm. B: Image recorded after the Dor myoplasty. Note the position of the patch and the obliterated apex of the left ventricle. The remaining left ventricular cavity has relatively normal geometry and systolic function.

62. Pseudoaneurisma Inferior FIGURE 15.57A . Off-axis transthoracic apical view (A) and transesophageal echocardiographic view (B) recorded in a patient with an inferior pseudoaneurysm. A: Note the proximal inferior wall aneurysm that appears to have a communication between the left ventricle ( LV ) and aneurysmal cavity that is relatively narrow ( arrows ). B: In the transesophageal echocardiogram, note the true extent of the pseudoaneurysm ( large arrow ) compared with the communication to the left ventricle ( small arrows ), which allows documentation that this is a pseudoaneurysm rather than a true aneurysm. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

65. Pseudoaneurisma Clasico Inferior

66. ETE con IM y Pseudoaneurisma FIGURE 15.57B . Off-axis transthoracic apical view (A) and transesophageal echocardiographic view (B) recorded in a patient with an inferior pseudoaneurysm. A: Note the proximal inferior wall aneurysm that appears to have a communication between the left ventricle ( LV ) and aneurysmal cavity that is relatively narrow ( arrows ). B: In the transesophageal echocardiogram, note the true extent of the pseudoaneurysm ( large arrow ) compared with the communication to the left ventricle ( small arrows ), which allows documentation that this is a pseudoaneurysm rather than a true aneurysm. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

67. ETE con IM y Pseudoaneurisma FIGURE 15.58 . Transesophageal echocardiogram recorded in a patient with an inferior myocardial infarction and a very large pseudoaneurysm. In this example, the outer boundary of the pseudoaneurysm is as marked by the outer vertical lines ( O ) and the communication with the left ventricle ( LV ) by the inner vertical lines ( I ). In this example, the maximal dimension of the pseudoaneurysm actually exceeds the size of the left ventricle. The opening to the pseudoaneurysm is noted by the smaller arrows . LA, left atrium; MV, mitral valve.

68. Peudoaneurisma Apical FIGURE 15.59A . Apical view recorded in a patient with a chronic small apical pseudoaneurysm. A: An off-axis four-chamber view. B: A two-chamber view. In each instance, note the very discrete, nearly spherical pseudoaneurysm cavity bounded by a fairly echodense border, suggesting calcification in the rim. The pseudoaneurysm has a very narrow neck communicating with the cavity of the left ventricle near the apex. In this case, the pseudoaneurysm is the result of apical infarction noted to have occurred 5 years before recording this echocardiogram. LA, left atrium; LV, left ventricle; RV, right ventricle.

69. Pseudoaneurisma Post-IM FIGURE 15.60A . Apical four-chamber view recorded in a patient with a large pseudoaneurysm after lateral wall myocardial infarction. A: Note the very large pseudoaneurysm cavity communicating with the left ventricle by a relatively narrow neck ( arrows ). B: Image recorded with color flow Doppler imaging confirms the communication between the left ventricular cavity and the pseudoaneurysm. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

72. Infarto Anteroapical y Trombo Apical FIGURE 15.63A . Apical long-axis (A) and four chamber (B) views recorded in a patient with an anteroapical myocardial infarction and a laminar apical thrombus. In each instance, note the laminar filling defect ( upward-pointing arrows ) in the apex of the left ventricle ( LV ), which is akinetic and dilated. B: Note the multiple laminar lines (downward-pointing arrow) with variable consistency of the thrombus suggesting chronicity. LA, left atrium; RV, right ventricle.

73. Trombo Apical FIGURE 15.64 . Apical four-chamber view recorded in a patient with an acute anteroapical myocardial infarction and a pedunculated, slightly mobile apical thrombus.

74. Trombos Multiples FIGURE 15.65 . Apical two-chamber view recorded in a patient with an anteroapical myocardial infarction and multiple large pedunculated and mobile thrombi. Note the multiple masses protruding into the cavity of the left ventricular apex and the mobile nature of these thrombi in the real-time image.

76. Trombo Apical FIGURE 15.66A . Apical four-chamber view recorded without (A) and with (B) intravenous contrast for left ventricular opacification. A: Note the vague suggestion of a filling defect in the apex of the left ventricle ( LV ) ( arrows ). B: After injection of intravenous contrast, the entire left ventricular cavity is opacified and the thrombus appears as a slightly mobile spherical filling defect in the left ventricular apex ( arrows ).

79. Miocardiopatia Dilatada Isquemica FIGURE 15.68 . Apical four-chamber view recorded in a patient with an ischemic cardiomyopathy and restricted posterior leaflet motion. A: Recorded in diastole. Note the position of the posterior leaflet ( arrow ). In systole (B) , there is normal motion of the anterior leaflet toward the tip of the posterior leaflet, which has remained tethered in position (arrow) due to the underlying wall motion abnormality. This abnormal coaptation results in functional mitral regurgitation. LA, left atrium; LV, left ventricle.

81. Post-Trasplante Cardiaco FIGURE 15.76 . Apical view recorded in a patient status post-cardiac transplantation who has undergone multiple right ventricular endocardial biopsies. A: Note the continuous turbulent flow in the right ventricular apex, which is the result of an iatrogenic coronary artery fistula into the cavity of the right ventricle ( RV ). B: A color Doppler M-mode recording through that area demonstrates the continuous flow. LV, left ventricle; RA, right atrium.

82. Enfermedad de Kawasaki FIGURE 15.77 . Parasternal short-axis view recorded at the base of the heart in a child with Kawasaki disease and aneurysmal dilation of the right coronary artery ( RCA ). Note size and location of the aorta ( Ao ) and pulmonary artery and a markedly dilated right coronary artery that measures approximately 8 mm in diameter. LMCA, left main coronary artery; RA, right atrium; RVOT, right ventricular outflow tract.