An Incidental Cause
The patient has a large thrombus (red arrow) touching the mid anterior septal wall! This came as a surprise to us, as the patient insisted he had been well (even after direct questioning after the echo). This, or rather, what had embolized, could have easily caused a stroke. Imagine what would have happened if the entire thrombus is dislodged. The patient also has a grossly abnormal E Point Septal Separation of around 1.5cm (yellow arrow). An EPSS of >7mm is sensitive though not specific for systolic dysfunction. This patient also has a significant diastolic heart failure (discussed in future).
Take a look in real time:
You can see that the anterior septal wall is akinetic. When one side of the heart is down, the less abnormal side (inferior lateral in this case) will try to compensate by working harder.
In the apical four chamber view, you can see that the thrombus arises from and is adherent to the mid inferior septal wall:
There is also marked regional wall motion abnormality of the anterior and septal walls in the parasternal short axis view (basal segments). This correlates with the poor R wave progression on the anterior leads seen on the ECG:
The underlying cause for this stroke is a left ventricular thrombus, on the background of poor systolic function. The new clinical picture and echo findings were discussed with the attending neurologist. Thrombolysis is held off; and the patient was anticoagulated instead. The transient heart failure resolved with judicious BP control and diuretics. He was admitted for further management. The formal echo reported a visual EF of 20%. The patient has a modified rankin scale of 1 upon discharge.
Point of care ultrasound provides 3 pieces of information: Anatomy, Pathology & Physiology. Train your eyes to see all three!
Lung ultrasound can rapidly identify an acute interstitial syndrome.
Echo when or better still, whenever, ECG is concerning; you never know what you're going to see.
McKaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014 Jun;32(6):493-7.
Dr. Toh Hong Chuen
Acute and Emergency Care Centre, Khoo Teck Puat Hospital. Singapore