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Echo Rounds

National Board of Echocardiography Exam Applications

Echo Case

Patrick Harkins, MD1; Rebecca M. Gerlach, MD FRCPC2

  1. CA-2 Resident
  2. Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL

A 74-year-old female with a past medical history of hypertension and hyperlipidemia was admitted to the intensive care unit (ICU) in cardiogenic shock after a late presentation ST-elevation myocardial infarction (STEMI). The patient was stabilized with intra-aortic balloon pump (IABP), inotropes, and oxygen therapy. A coronary angiogram performed at that time showed a total occlusion of the proximal left anterior descending (LAD) artery. A transthoracic echocardiogram (TTE) performed upon presentation was significant for left ventricular (LV) function of 53% with apical and septal akinesis, moderate dilation of the right ventricle (RV), moderately depressed RV function, and elevated RV systolic pressure of at least 50 mmHg.

Despite intensive treatment, she developed acute renal failure, remained oxygen dependent, and was unable to be weaned from the IABP. She was brought to the operating room for coronary artery bypass grafting 10 days later. The following transesophageal echocardiography (TEE) images were acquired, which were significant for several relevant findings.

Video and Figure Legends

Image 1: Transgastric LV Long Axis View

Image 2: Transgastric LV Short Axis View-Color

Image 3: 3D 4-Chamber View

Questions

  1. The preceding TEE images are consistent with which of the following diagnoses? (Choose all that apply.)
    1. Takotsubo cardiomyopathy
    2. LV aneurysm
    3. Muscular ventricular septal defect (VSD)
    4. Prominent moderator band
  2. What is the best management option for treatment of the defect(s) present?
    1. Percutaneous occluder device
    2. Conservative treatment with medical management
    3. Coronary artery bypass grafting (CABG) only
    4. Surgical patch repair, CABG and Dor procedure