MODALITAS DIAGNOSTIK

KARDIOVASKULER

Ali Ghanie

Division of cardiology,Department of Internal

Medicine, Faculty of Medicine Sriwijaya University,
Palembang
Modalitas

 Pemeriksaan diagnosis fisik

 Laboratorium
 Elektrokardiogram
 Chest x Ray
 Echocardiography
 Magnetic resonance imaging
 Kateterisasi
Pemeriksaan fisik

 Sebagian besar dapat ditegakkan

dengan fisik
 Kardiomegali, bunyi jantung, bising
tambahan, gallop
 Edema paru-paru, edema sistemik,
JVP, hepatomegaly, edema tungkai
Chest X-Ray
Sketsa Jantung pada Foto Dada
JANTUNG NORMAL DENGAN PPM
FOTO RONTGEN THORAK AP,
CTR >, SEG PULMONAL DAN
ATRIUM KIRI >
CTR >, LV embedded
Kerley A line (+)
CTR >, vasc hilus >
CTR>, Shoe shaped,
apex embdded
ASD II, CTR >, segm a.pulm >,
CTR>, shoe shaped, vasc
marking>, mass paracardial
kanan
CTR >, LA, LV>, RV> (?)
MS Berat dengan Pembesaran
Jantung Kanan
 ASD II, DENGAN
ESSENMENGER SYNDROME
Akut Pulmonary Edema
Gagal Jantung dengan
Hipertensi Pulmonal dan
Kyposis
MS, MR
ASD II
ASD II dengan
Eisenmenger Syndrome
Mitral Stenosis Berat
Efusi Perikard
Mitral Stenosis
HHD
Congestive heart failure ec
MS/MR/AR/TR ec RHD
Congestive heart failure
ec MS/MR/AR/TR ec
RHD (perbaikan)
Edema Paru
Nyeri dada kiri, Riwayat CAD
(foto 1)
Klinis dugaan Pleuropneumoni
kiri.
Ekspertisi radiologi : curiga awal
bendungan paru
Nyeri dada kiri, Riwayat CAD
(foto 2)
4 hari post terapi antibiotik.
Ekspertisi radiologi : Aorta
sclerotic. Tidak tampak infiltrat
maupun efusi pleura
Echocardiography
What is echo?

 Machine with ultrasound base

 Imaging modalities of the heart, wall,
vessel, and valve
 Color flow modalities for assessing
flow direction
 Doppler modalities for hemodynamic
measurement, stroke volume, cardiac
out put
What the echo can tell in
HF ?
 Is there systolic dysfunction?
 How the wall motion abnormality looks
like
 Is it general or regional wall motion
abnormality ?
 Is there any valve problem? Primary or
secondary?
 LVH without valve problem, is it HHD
or HCM / HOCM
DIASTOLIC HF

 Symptomatic patient
 Some time normal CTR from chest x
Ray
 Systolic function (EF) normal
 Filling pattern reversed, or
pseudonormal
 Left atrial enlargement
EJECTION FRACTION

 Percentage of ejected blood during

systole
 Measured by M mode, or bullet
 Normal range > 50%
INTRODUCTION

 Most acquired or congenital cardiac

disease are associated with systolic
or diastolic LV dysfunction
 Assessment For SV provide a
valuable prognostic information
 Should be a routine procedure in
echo exam
GENERAL PRINCIPLES
 Linear measurement from the M-mode for LV
dimension during systole and diastole and EF
and FS
 With the 2-D echo, area, volume, SV, COP
could be measured
 Doppler, intra cardiac blood flow, systolic flow
measurement made possible.
 Advanced Echo, tissue Doppler, strain rate,
sophisticated procedure for LV function
M-MODE ECHO

 Linear measurement of minor axis

dimension from M-mode
 Mostly guided by 2-D echo
 Resolution for precise timing is
superior, but Visualization of entire
LV is poor
Linear measurement of LV and
function
 End diastolic diameter (EDD)
 End systolic diameter (ESD)
 Fractional shortening (FS)
 Ejection fraction (EF)
 Cubed LV volume in diastole (EDD)3
 Cubed Lv volume is systole (ESD)3
Diagram echo 2-D pada potongan memanjang menunjukkan diameter akhir
diastole dan systole (garis titik-titik)
Trans thorakal Ekho M-mode dengan bimbingan ekho 2-D menunjukkan
interogasi linier yang memenuhi syarat, dengan fungsi sitolik ventrikel kiri yang
normal
Transthorakal Ekho M-mode dengan bimbingan echo 2-D pada potongan
basis jantung pada orang normal, terlihat gerakan basis jantung pada saat
systole menebal sampai 1.79 cm
Parameter ekho normal laki-laki ( n = 79)
Parameter echo Range Mean SD
EDD 3.10 – 4.90 4.02 0.4580
ESD 1.50 – 3.30 2.069 0.3799
IVS 0.70 – 1.00 0.844 0.07
PW 0.70 – 0.90 0.772 0.078
FS 28.0 - 58.0 48.25 7.93
EF 63.0 - 90.0 80,307 4.07
A0 2.20 – 3.60 2.867 0.245
LA 1.70 – 3.00 2.217 0.412
LVM 53.53 - 177.41 106.087 29.5619
LVMI 36.42 - 101.12 67.4192 17.5942
RWT 0.23 – 0.53 0.388 0.05326
BW 47.0 - 72.00 59.33 8.033
H 154.0 - 179.0 163.359 5.98
BSA 1.34 – 1.80 1.6213 0.1042
Sumber : A.Ghanie. Parameter echo normal. Buku ajar Penyakit Dalam
Paremeter ekho normal pada wanita (n = 79)
Parameter ekho Range Mean SD
EDD 3.20 - 4.60 3.9353 0.3549
ESD 1.50 - 3.30 2.1324 0.3607
IVS 0.60 - 1.00 0.8147 8.214E-02
PW 0.50 - 0.90 0.7176 8.338E-02
FS 27.00 - 57.00 46.0294 7.2007
EF 61.00 - 90.00 81.2941 5.9520
A0 2.00 - 3.10 2.7088 0.2927
LA 1.80 - 3.00 2.2324 0.4290
LVM 35.01 - 157.85 95.0418 29.4444
LVMI 23.34 - 108.82 61.1988 18.8395
RWT 0.30 - 0.45 0.3761 4.199E-02
BW 48.00 - 70.00 55.6029 7.1189
TB 153.00 - 180.00 163.4412 7.2329
BSA 1.42 - 1.77 1.5718 8.266E-02
Sumber : A.Ghanie. Parameter echo normal. Buku ajar Penyakit Dalam
Parameter normal
Parameter Normal Range Pt. Pop.

Fraction Shortening (%) 28-44 (mean 36) 208

Ejection Fraction (%) 64-83 (mean 74) 208

Stroke Volume (cc) 75-100 …

Cardiac Output (L/min) 4-8 …

Cardiac Index (L/min/m2) 2.8-4.2 (mean …

3.4)
circulation
Transthorakal Ekho M-mode dengan bimbingan ekho 2-D pada pasien gagal
jantung, namun septum dan dinding belakang masih menunjukkan gerakan
normokinesis
Ekho M-mode dengan bimbingan ekho 2-D pada pasien gagal jantung, menunjukkan
dilatasi ventrikel kiri, gerakan septum dan dinding belakang hipokinesis.
Transthorakal Ekho M-mode dengan bimbingan echo 2-D pada pasien
gagal jantung menunjukkan jarak puncak E dengan septum 1.96 cm.
Limitation of M-mode
 Can be used only in normal geometry and
symmetric function.
 under or overestimate of LV function in
Ventricle aneurysm, regional wall motion
abnormality, or interrogation not
perpendicular
2-D ECHO MODALITY

 2-D echo is superior in determining LV

size and function.
 Calculation of EF can be done by
simplified method from 3 separate minor
axis dimension at the base, mid, and
distal from apical view
 Simpson rule, one of the most common
use in measuring LV systolic function,
from the apical 2 or 4 chambers
Transthorakal Ekho 2-D pada pasien dengan infark jantung menunjukkan daerah
hipokinesis pada daerah basal & anterosptal
Transthorakal Ekho 2-D pada pasien dengan infark jantung anteroseptal menunjukkan
daerah yang hipokinesis pada daerah anteroseptal
Limitation of 2-D, Simpson

 Interogation of single plane of LV in

certain condition not represent LV
function.
 From apical 2 or 4 chamber axis,
sometime the chamber foreshortened.
 Myocardial drop out of the apex
 Complete delineation of the
endocardium is often dificult, tissue
harmonic modalities can help
REGIONAL LV FUNCTION
 Wall motion analysis
 Myocardial strain, strain rate imaging
Regional Wall motion analysis
Transthorakal ekho 2-D menunjukkan aneurisma anteroseptal dan apek dengan
ejeksi fraksi area 6%
Doppler for LV Function

 The concepts is simple base on Time

velocity integral and cross sectional of
certain area, from which SV and COP
and CI can be measured.
 Left ventricular dP/dt, represent the rate
of increase in pressure in LV
Stroke Volume by Doppler
SV = D2 x 0.785 x TVI
SV = 2.42 x 0.785 x 19
= 86 cc

Stroke Volume by Doppler

Transthorakal Ekho dopler warna melalui mitral penderita Mitral regurgitasi,
waktu yang dibutuhkan untuk mencapai velositas 3 m/sec adalah 0.022 sec,
sehingga diperoleh data dP/dt 32:0.022 yaitu 1455
Clinical significance of the dP/dt in the
assessment of left ventricular systolic
function

Left Ventricular dP/dt Value Time taken for LV

Systolic Function (mm Hg/sec) to generate 32 mm
Hg
Normal > 1,200 < 0,027sec (27 ms)
Mild- 800 – 1,200 0.027 – 0.040 sec
moderatedysfunction (27 ms – 40 ms)
Severe dysfunction < 800 > 0.040 sec (40 ms)
sumber: Nishimura, R.A. and Tajik, A.J.: Quantitative hemodynamics by Doppler
Echocardiography : A noninvasive alternative to cardiac catheterization. Progress in
Cardiovascular Disease 4: 332, 1994.
Dopler jaringan dari annulus mitral
SUMMARY
 The role of echo with different modalities in assessing
LV systolic function had been documented
 Ejection Fraction, fractional shortening stroke
volume,and cardiac out put are routine parameters in
detecting LV systolic function, and can be performed
in a simple echo machine.
 Certain parameters such as RWM scoring, tissue
strain, and tissue doppler are rather specific
procedure with the necessity of advanced machine
and technology.
Ringkasan

 Fraksi ejeksi, fraksi pendekan, isi

sekuncup, curah jantung, merupakan
parameter rutin dalam pemeriksaan
fungsi sistolik ventrikel kiri, dan dapat
dilakukan umumnya pada mesin ekho
yang sederhana.
 beberapa parameter seperti skoring
gerakan dinding, strain miokard, dopler
jaringan dan merupakan pemeriksaan
khusus membutuhkan pendalaman lebih
lanjut, dan memerlukan mesin ekho
yang lebih canggih serta mahal.
Magnetic Resonance
Imaging
KATETERISASI
CIRCULATORY CIRCUIT

PARU

Kanan Kiri