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INTRODUCTION

Congestive heart failure has been defined as a clinical syndrome that occurs when the heart is unable to meet the demands of actively metabolizing tissue without increasing filling pressures. Myocardial causes of heart failure (HF) may be systolic and/or diastolic. The versatile, noninvasive nature of echocardiography means that it plays a part in the diagnosis, determining the etiology, and noninvasive evaluation of HF guide management. This chapter will highlight the role of echo in evaluating a few cases of systolic dysfunction and diastolic dysfunction.

PATIENT CASE: ISCHEMIC CARDIOMYOPATHY

Mrs. LH is a 66-year-old woman who uses a wheelchair. She has a past history of recent myocardial infarction s/p percutaneous coronary intervention (PCI) to a large left anterior descending artery (LAD) (Video 21-1, Figure 21-1, Video 21-2, Video 21-3) and left circumflex artery (LCX), and history of congestive heart failure (CHF) with medical noncompliance, hypertension (HTN), and hyperlipidemia. Mrs. LH was seen in clinic with worsening pedal swelling and decreased ability to lie down flat at night. She had a history of dietary and medical noncompliance and was brought in by her husband who complained that his wife was getting worse. She denied new onset of chest pain but admitted that she had not been compliant with her carvedilol medication out of concerns that it may precipitate an undue drop in blood pressure.

Figure 21-1

Parasternal long-axis view of another patient with thinned anteroseptal wall. Three-chamber view of patient with ischemic cardiomyopathy showing severely hypokinetic anterior wall and apex.

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VIDEO 21-01: Patient with ischemic cardiomyopathy with thrombus in inferior wall to apex (two-chamber view).

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VIDEO 21-02: Patient with ischemic cardiomyopathy showing severely hypokinetic anterior wall and apex (three-chamber view).

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VIDEO 21-03: Severely hypokinetic apex and septal walls (four-chamber view).

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On examination, Mrs. LH’s jugular venous pressure was elevated with a prominent V wave and she had a soft systolic murmur over her tricuspid area, which got louder with inspiration. Also present was a soft S1 with a prominent third heart sound. She also had bilateral crackles over her lung bases, bilateral pedal edema, and chronic stasis dermatitis. Her electrocardiogram (ECG) was unchanged from her previous ECGs and 3 sets of troponins were negative. Echocardiography revealed an ejection fraction (EF) of 32% with anterior wall motion abnormalities and a prominent left ventricular thrombus at the apex (Video 21-1, Video 21-4, Video 21-5). She was then admitted and maintained on oral lisinopril daily, intravenous (IV) frusemide, and IV heparin with warfarin. She was eventually discharged after achieving euvolemic status on the same medicines with ...

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