A New Window of Opportunity in Echocardiography

The usefulness of trans-splenic retrocardiac imaging in prone positioned critically ill patients

In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome and this maneuver is now considered a simple and safe method to improve oxygenation. Hemodynamic monitoring by echocardiography may be required but prone positioning imposes certain challenges limiting standard examination. The article describes the application of the "trans-splenic retrocardiac view," a little-known echographic window for obtaining Doppler parameters from the back in prone-positioned patients.

Case Report: Posterior Thoracic Window in the Presence of Pleural Effusion in Critical Care Medicine: One More Chance to Image the Aortic Valve

Good quality echocardiographic images in the setting of critical care medicine may be difficult to obtain for many reasons. We present a case of an 85-year-old woman with acute pulmonary edema and pleural effusion, where transthoracic bedside echocardiographic examination raised a suspicion for significant aortic valve disease. However, given the orthopneic decubitus of the patients, the quality of images was poor. To increase the accuracy of diagnosis, a posterior thoracic view through the pleural effusion in the sitting position was used. This view allowed the diagnosis of mixed aortic valve disease (aortic stenosis and regurgitation) and the quantification of valve disease through multiparametric criteria as recommended by current guidelines. The posterior thoracic view, when feasible, may provide a useful option in the assessment of cardiac structures and further diagnostic information in technically difficult echocardiographic examinations.

Transthoracic ultrasound; seeking the heart in a patient with a large left-sided cirrhotic hydrothorax

A case of a patient with liver cirrhosis and a large left-sided pleural effusion displacing the heart rightward is presented and the best views to acquire images enabling evaluation of the cardiac function are highlighted. Understanding the modified intrathoracic anatomy in patients with pleural effusions enables quick and focused assessment and can shorten evaluation time while preserving high image quality.

Left Posterior Thoracic Acoustic Window: A Forgotten Approach for Aortic Stenosis Assessment

Accurate diagnosis of severe aortic stenosis is important for timely valve replacement. Peak aortic velocity and gradient recordings require optimal aortic jet-ultrasound beam alignment, which may be challenging in patients with poor acoustic windows due to obesity, lung disease, chest deformities, skin lesions, or surgical scars. In these clinical settings, alternative acoustic windows, notably the posterior thoracic window, can be helpful. However, in order to use the posterior thoracic window, some degree of left pleural effusion must be present.

Evolution of the pericardiocentesis technique

: Pericardiocentesis is a valuable technique for the diagnosis and treatment of patients with pericardial effusion and cardiac tamponade, although it may be associated with potentially serious complications. Through the years, many different imaging approaches have been described to reduce the complication rate of the procedure. This systematic review provides a focused overview of the different techniques developed in recent years to reduce the procedural complications and to increase the related success rate.

Assessment of left ventricular function with magnetic resonance imaging vs. echocardiography, contrast echocardiography, and single-photon emission computed tomography in patients with recent ST-elevation myocardial infarction

AIMS

Magnetic resonance imaging (MRI) is often considered to be the gold standard in measuring left ventricular function and volumes. The aim of this study was to assess the agreements between standard echocardiography (standard echo), contrast echocardiography (contrast echo), single-photon emission computed tomography (SPECT), and MRI in the determination of left ventricular ejection fraction (EF) and end-diastolic volumes (EDV) in patients treated for acute ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

Standard echo, contrast echo, SPECT and MRI were performed on the same day, 3 months after STEMI in 150 patients participating in the NORwegian Study on District Treatment of ST-Elevation Myocardial Infarction (NORDISTEMI). Bland-Altman analysis of EF measured by all four imaging modalities showed generally low mean differences but wide limits of agreement. The mean EDV difference, however, was consistently higher when MRI was compared with standard echo (54.9 mL), contrast echo (41.7 mL) and SPECT (54.6 mL), and the limits of agreement were wider. The mean EDV differences between contrast echo vs. standard echo, SPECT vs. standard echo and contrast echo vs. SPECT were small.

CONCLUSION

Our data suggest that all four imaging modalities measured EF closely similar after STEMI as demonstrated by a very small bias. The limits of agreement were however wide. EDV measured by MRI was consistently higher when compared with the other methods which may be caused by different tracing-methods and imaging principles. As echocardiography is preferable from a cost-benefit point of view, further analysis would be needed to clarify the nature of such differences.

Transthoracic echocardiography after heart surgery: could pleural view be of some help?

The pericardial effusion localized on the upper portion of the right atrium is a classical complication of the post-operative heart surgery setting. This issue is most likely not visualized by transthoracic echocardiography and needs the transoesophageal approach. The present case reports a situation where an associated bilateral pleural effusion permitted a new view of the heart which has been helpful to confirm the diagnosis of tamponade and to re-transfer the patient to the operative room.