Heart diseases treatment by Doppler ultrasound

2021-08-07 07:32 PM

In patients with no symptoms, the treatment includes prevention and monitoring when heart failure, not having surgical conditions, using low-dose digoxin and diuretic.

Heart diseases treatment by Doppler ultrasound

Heart diseases treatment by Doppler ultrasound

Heart valve diseases can be treated or combined with medical and surgical treatment, depending on the stage and cause.

Mitral valve regurgitation

Mitral valve regurgitation can be acute or chronic, can be alone, or combined. The main cause is rheumatic heart disease, about 20% of which are physiological in normal people.

Severe mitral valve regurgitation, EF 40 - 50% is a lot of myocardial damage, if EF < 40%, the risk of surgery is very high, even if myocardial valve replacement is not reversible.

When you see that the leaflets are thickened, the movement of the posterior leaflet is reduced, the anterior leaflets are prolapsed or shortened, the ligaments are thick, and they stick together: think of the low posterior mitral regurgitation.

An image of the valve ring with high density can be seen with a dorsal shadow: calcification of the valve ring.

Warts, ruptured ligaments cause valve prolapse, possibly torn valve leaflets for peripheral open flow: Osler.

The leaflets are thick, long, and prolapsed: Mucine degeneration.

Electrocardiogram: the most common is left atrial dilatation or atrial fibrillation. A few have left ventricular dilatation, right ventricular thickening.

Internal treatment

ACE inhibitors, digoxin in atrial fibrillation (medical treatment does not reduce disease progression, immediate surgery is required).

Surgical treatment

Mitral regurgitation ≥ 3/4 + NYHA ≥ 3: surgery.

Mitral regurgitation ≥ 3/4 + NYHA ≥ 2: follow-up, if left atrium, left ventricle enlarge or atrial fibrillation occurs, surgery is required.

Poor prognosis at surgery: elderly patient, NYHA 4, little remission with medical therapy, combined coronary artery disease, left ventricular diameter > 25% of normal, pulmonary artery pressure > 100 mmHg, EF < 40 % (EF in patients with normal mitral regurgitation > 70%, even in severe disease, decompensated heart failure EF is only slightly reduced).

Mitral valve stenosis

The mitral valve consists of 2 leaflets, large anterior leaflets, and small posterior leaflets. The valvular orifice area (S) during diastole 4-6 cm2, is considered narrow when S ≤ 2 cm2 (1.2 cm2/m2 skin). Tight when S ≤ 1 cm2 (0.6cm2/m2 skin).

When pulmonary artery pressure > 70 mmHg will exceed right ventricular tolerance => right ventricular failure and tricuspid regurgitation.
 
Mild mitral regurgitation when: S > 2 cm2, moderate: 1 - 2 cm2, weight < 1 cm2, very heavy < 0.8 cm2.

Internal treatment

Low room, prevention of infective endocarditis when tooth extraction...

Only functional symptoms can be reduced, but disease progression cannot be prevented.

Beta-blockers to slow heart rate, digoxin in the presence of atrial fibrillation, diuretics in the presence of pulmonary hypertension or right heart failure, anticoagulation in the presence of atrial fibrillation or left atrial coagulation or stenosis in which the left atrium is > 50 mm.

Surgical treatment

Valve dilation - repair the valve when the valve is minimally damaged and when:

Closed mitral valve stenosis.

Severe mitral stenosis + new complications of atrial fibrillation.

Severe mitral stenosis + NYHA ≥ 2.

Having an embolic attack with or without anticoagulation.

Accompanied by pulmonary hypertension.

Valve replacement:

Valve damaged a lot + NYHA ≥ 3.

Aortic valve regurgitation

The valve leaves are thick but still open: low posterior.

Two-piece aortic valve.

The sigmoid valve prolapses into the left ventricle: prolapse.

Warts on the leaflets, valve edges, sometimes tearing the valve, can see the sigmoid valve inverted into the left ventricle: Osler.

Ascending aorta > 42 mm diameter + parallel septal separation > 16 mm => aortic dissection.

Increase in aortic diameter > 55mm: aortic aneurysm.

Valsalva sinus aneurysm: prolapse of an aortic sigmoid valve into the heart chamber, usually the right ventricle, sometimes the right atrium, and very rarely the left ventricle.

When left ventricular diameter > 70 mm at diastole and especially > 50 systolic, with contractile fraction < 25%, it is a sign of myocardial damage, requiring surgery.

Internally treatment

Prevent rheumatic fever, prevent endocarditis, treat heart failure.

When there is no left ventricular dysfunction, only diuretics + vasodilators are used. When the left ventricle is large, the EF decreases, requiring more digoxin (vasodilators start with low dose => ACE inhibitor, Ca blocker).

Grade 1 - 2 aortic regurgitation without heart failure does not require treatment, grade 3 - 4 regurgitation even though there are no symptoms should consider vasodilators, nifedipine can slow left ventricular dysfunction.

Surgical treatment

Aortic regurgitation + NYHA ≥ 3 95% mortality after 10 years.

Aortic regurgitation grade ≥ 3 + NYHA ≥ 3 require surgery even though there is no left ventricular dysfunction.

EF < 55%, left ventricular systolic diameter > 50 mm: schedule surgery in 12 months even if no symptoms.

Aortic regurgitation + no functional symptoms or no left ventricular dysfunction: Follow up every 3-6 months.

Chronic aortic regurgitation:

Functional symptoms (NYHA 3)

  +       +       -       -

EF < 50%

 

-       +       +       -

Note  

1       2       3       4

1- Surgery.

2- Considered because of the high surgical risk.

3- Surgery.

4- Follow up every 6 months.

Aortic valve stenosis

Normal aortic valve opening area: 3 - 5cm2, 50% reduction in the area does not create a significant pressure difference. Severe aortic stenosis when the area is ≤ 30% of normal (≤ 1cm2), very severe when the area is ≤ 0.75cm2.

Assess severity by mean gradient (true when cardiac output is normal) < 25; 25 - 50; > 50 mmHg.

Internal treatment

In patients with no symptoms, the treatment includes prevention and monitoring when heart failure, not having surgical conditions, using low-dose digoxin and diuretic.

When there is atrial fibrillation, they should be transferred to the sinus soon because the cardiac output is already low, now there is atrial fibrillation => decrease by 20%.

Surgical treatment

Children with surgical aortic stenosis when mean transvalvular pressure gradient 70 mmHg

Adults: surgery before left ventricular dysfunction, when EF is severely reduced, although surgery also improves poorly.

Severe aortic stenosis + acute symptoms => immediate surgery.

Patients with aortic valve stenosis: 100% need to be monitored every 6 months, when EF decreases even though there are no functional symptoms, surgery is also indicated.

Tricuspid valve regurgitation

Annulus dilatation is usually in the anterior leaflet.

True tricuspid regurgitation is usually caused by rheumatic heart disease, mainly by retraction of the posterior leaflet.

Tricuspid valve prolapse often with 2 leaves, due to dysplasia, congenital.

Diagnosis and quantification by Doppler ultrasound

2D: diagnosis is confirmed when the inferior vena cava is constricted in diameter > 24mm; Do not consider when inferior vena cava < 16mm.

Diagnosis is confirmed when the hepatic vein is <18mm in diameter.

Doppler: hepatic vein determines the severity.

Color Doppler: Gradient.

Treatment

Medical: digoxin, vasodilator, diuretic in heart failure

Surgery: conservative treatment is the main, functional tricuspid regurgitation is only indicated for repair along with other valve surgery

Mild functional tricuspid regurgitation: no treatment needed.

Moderate functional tricuspid regurgitation: correction of the posterior tricuspid valve annulus.

Severe mechanical tricuspid regurgitation: insert an artificial valve ring.

Physical tricuspid regurgitation: an artificial valve ring must be placed.

Rip off valve edges if sticky.

Enlargement of the valve tissue with the pericardium if the valve tissue shrinks can remove the traction ligament.

Heart attack

Localized disorders of ventricular motor: decreased movement, no movement, paradoxical movement (90% of transmural disorders have focal disturbances).

Change in ventricular wall thickness: there is no decrease in ventricular wall thickness during systole.

Structural changes: the scar area under the Echo will be brighter than usual.

Monitor for improvement in focal motor and left ventricular function during thrombolytic therapy.

Severe prognosis is based on the extent of the infarct, and venous ultrasound does not cut the infarcted area because the results are inaccurate.

Detection of complications: aneurysm, ventricular septal defect, mitral regurgitation, free septal rupture, ventricular thrombosis...

Pericardial disease

Pericardial effusion

Echo gap at the back of the heart.

The space is greatly reduced and completely lost at the junction of the left atrium and the left ventricle.

The pericardium is not active.

When covering the whole heart, see clearly => fluid ~ 300ml, if > 1cm => fluid > 500ml, if fluid ≥ 2cm => fluid > 700ml (subcostal view of systolic vasculature).

Notice lowering the gain.

Heart block

2D: the collapse of the right ventricle, right atrium, and left atrium.

Doppler: Normal velocities across the atrioventricular and pulmonary valves change less than 20% cyclically. Cardiac blockade velocities increase > 40% of right heart and decrease > 40% of left heart.

Constrictive pericarditis

Pericardial thickening (> 1mm) is one thick line or two parallel lines or more parallel lines.

Increase the E/A ratio.

In constrictive pericarditis, blood flow velocities in the inferior vena cava increase during systole; in rate-restricted cardiomyopathy, it increases in early diastole.

Dilated cardiomyopathy

Cardiac chambers are enlarged.

Normal wall thickness.

Left ventricular systolic function is severely reduced, diastolic abnormality.

When symptoms are present, 25% die within the first year, 50% die within 5 years.

Treatment: Diuretic, a vasodilator (ACE inhibitor), digoxin, beta-blockers.

Hypertrophic cardiomyopathy

Small heart chamber size.

Cardiac wall thickness increases.

Hyperactive systolic function, abnormal diastolic function.

Left ventricular ejection fraction.

Diastolic ventricular septum/left ventricular posterior wall ≥ 1.3 (normal: 0.9 - 1.3).

Treatment: β-blocker, case-blocker, antiarrhythmic.

Restrictive cardiomyopathy

Normal ventricular size, atria dilated.

Normal wall thickness.

Left ventricular systolic function is normal or decreased.

Doppler: wave abnormalities across the atrioventricular valve, waves do not change with respiration (constrictive pericarditis is often present).

Treatment of congestive heart failure: digoxin, diuretic, vasodilator.

Endocarditis

Transthoracic ultrasound helps to show warts in 50-80% of cases (diameter ≥ 3mm).

Treatment: high-dose antibiotics for 4-6 weeks.

Aortic dissection

The aorta is located in the medial layer.

The aorta is both a conduit and promotes blood circulation: the velocity close to the wall = 5m/s, the velocity between the vessels is only 40 - 50cm/s.

The ascending aorta is 30 mm in diameter at the base.

95% dissection in ascending aorta, several centimeters from the valve or thoracic aorta

Ultrasound shows

Localized or diffuse aortic dilatation.

The aortic wall splits in half for 2 echo-enhanced images.

Blood clots or blood clots may be seen in the false lumen.

Color Doppler shows no flow or weak flow in the pseudobulbar, or the flow in the pseudolum is opposite to the true flow.