Transthoracic Echocardiogram - IAC Online Accreditation

[Pages:4]YOUNG, CAREY W 5001956428 12/19/2016

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Amended Report RIVERSIDE METHODIST HOSPITAL 3535 Olentangy River

Road Columbus, OH 43214 Phone: 614-566-5390

Fax: 614-566-6876

Transthoracic Echocardiogram

Patient: YOUNG, CAREY W DOB: 10/16/1942

Med Rec#: 5001956428

Age: 74y

Date: 12/19/2016

Height: 183 cm / 72.0 in

Account#: 6096642752

Weight: 92 kg / 202.8 lbs

Accession#: 1000002264455 BSA: 2.144140254058

Sex: M

Patient Type: Inpatient

Room#: 4006

Loc: CIL

Reading: Karanvir S. Grewal, MD Referring: Fikes, Richard A., DO Sonographer: Saunders, Molly RDCS, BA

History:

AICD implant. Anemia. Aortic aneurysm. Atrial fibrillation. Cardiomyopathy.

Congestive heart failure. COPD. Coronary artery disease. Diabetes. Hypertension.

Hypothyroidism. MV repair. S/P CABG. S/P Left Heart Cath. Tobacco abuse.

Diagnosis:

ICD-10-PCS Abnormal electrocardiogram [ECG] [EKG] (R94.31)

Abnormal EKG (794.31)

CPT Codes:

ECHO COMPLETE W/ DOPPLER (93306)

Conclusions

1. There is mild to moderate aortic stenosis. The aortic valve area by AVI is 1.5 cm2.

2. There is normal global and regional left ventricular systolic function. The estimated

ejection fraction is 55%.

3. Compared to prior report from 2011, LVEF has inproved markedly, AS now noted,

and transmitral gradients are higher.

Reason For Study: Abnormal EKG.

Summary:

Patient identity verified and ID band on (pause and confirm).Current H&P present on patient

chart.Procedure explained and patient verified understanding.Consent obtained for

procedure.A two-dimensional transthoracic echocardiogram with color flow, pulsed and

continuous Doppler was performed.The study was technically adequate.

Findings

Procedure Info: The study quality is fair.

Left Ventricle: The left ventricular chamber size is normal. Mild to moderate concentric left

ventricular hypertrophy is observed. Global left ventricular wall motion and

contractility are within normal limits. There is normal left ventricular systolic

function. The estimated ejection fraction is 55-60%. No regional wall motion

abnormalities are evident.

Left Atrium:

The left atrium is mildly dilated. A patent foramen ovale is not demonstrated by color

Doppler.

Right Ventricle: The right ventricular chamber size and systolic function are within normal limits. The

right ventricular cavity size is normal. The right ventricular global systolic function is

normal.

Right Atrium: The right atrial cavity size is normal.

Aortic Valve: The aortic valve is trileaflet. Moderate aortic leaflet calcification is visualized. There

is mild to moderate aortic stenosis. The peak instantaneous gradient of the aortic

valve is 50 mmHg. The mean gradient of the aortic valve is 27 mmHg. The aortic

valve area by AVI is 1.5 cm2. There is a trace of aortic regurgitation.

Mitral Valve: There is moderate mitral annular calcification. The mitral valve leaflets are mildly

thickened. There is mild to moderate mitral stenosis. The mean gradient across the

mitral valve is 11 mmHg. There is trivial physiological regurgitation of the mitral

valve.

Tricuspid Valve: The tricuspid valve leaflets are normal. There is mild tricuspid regurgitation. There is

evidence of borderline pulmonary hypertension.

Pulmonic Valve: The pulmonic valve appears grossly normal in structure and function.

Pericardium: There is no pericardial effusion.

Aorta:

The aortic root is normal in diameter.

BP: 157/71



1/31/2017

YOUNG, CAREY W 5001956428 12/19/2016 HR: 74

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1/31/2017

YOUNG, CAREY W 5001956428 12/19/2016

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Chambers 2D

Name

Value

IVSd (2D) LVPWd (2D) IVS:LVPW ratio (2D) LVIDd (2D) LVIDs (2D)

LVIDd (2D) index

LVIDs (2D) index

Ao root diameter (2D) Aortic root diameter (2D) index

1.36 cm 1.21 cm 1.12 ratio 4.9 cm 3.82 cm

2.29 cm/m2

1.78 cm/m2 3.3 cm

1.54 cm/m2

Measurements

Volumes/Mass

Normal Range

Name

Value

-

LA Area 2 CH

28.1 cm2

-

LA Area 4 CH

35.7 cm2

-

LA ESV SP 4CH (MOD) 139 ml

-

LA ESV SP 2CH (MOD) 97 ml

-

LA ESV BP (MOD)

122 ml

-

LA ESV BP (MOD) index

56.9 ml/m2

-

LV EDV SP 4CH (MOD) 120 ml LV ESV SP 4CH (MOD) 44 ml

-

EF SP 4CH (MOD)

63.33 %

-

LV EDV SP 2CH (MOD) 122 ml

LV ESV SP 2CH (MOD) 40 ml

EF SP 2CH (MOD)

67.21 %

LV EDV BP LV ESV BP

121 ml 43 ml

BP EF (MOD)

64.46 %

LV EDV BP index

56.43 ml/m2

LV ESV BP index

20.05 ml/m2

LV mass (2D)

249.52 g

LV mass (2D) index

116.37 g/m2

Normal Range

-

-

-

-

-

-

-

Diastolic/Systolic Function

Name

Value Normal Range

MV E-wave Vmax

1.97 m/sec

-

MV deceleration time 244 msec

-

MV A-wave Vmax 1.75 m/sec

-

MV E:A ratio

1.13 ratio (1.1 - 1.5)

LV septal e' Vmax

0.04 m/sec

-

LV lateral e' Vmax

0.06 m/sec

-

LV average e' Vmax 0.05 m/sec

-

LV E:e' septal ratio 44.87 ratio

-

LV E:e' lateral ratio 35.62 ratio

-

LV average E:e' ratio 39.72 ratio

-

Aortic Valve

Name

Value

AV Vmax AV VTI AV peak gradient AV mean gradient LVOT diameter LVOT Vmax LVOT VTI LVOT peak gradient LVOT mean gradient DOI (VTI) DOI (Vmax) SV LVOT CO LVOT

Cardiac index

AVA (continuity Vmax) AVA (continuity Vmax) index AVA (continuity VTI) AVA (continuity VTI) index Ascending Ao

3.54 m/sec 78.3 cm 50 mmHg 27 mmHg 2.5 cm

1.15 m/sec 23.5 cm 5 mmHg 3 mmHg 0.3 ratio 0.32 ratio 115.3 ml 8.53 l/min 3.98 l/min/m2 1.59 cm2 0.74 cm2/m2 1.5 cm2 0.69 cm2/m2 3.5 cm

Normal Range

(1 - 1.7) -

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