1. (قالوا سبحانك ل علم
لنا إل ما علمتنا إنك
أنت العليم الحكيم )
صدق ا العظيم

2. ECHO IN THE CORONARY
INTENSIVE CARE UNIT: DOES IT
REALLY IMPACT PATIENT
?MANAGEMENT
Thesis 
Submitted in Partial Fulfillment for Master Degree in 
.Cardiology
By 
.DR.Amr Ahmed Alshamy 

6.  Attention has been drawn to the limitations
of the physical examination for the
detection of cardiovascular abnormalities
that can be present in critically ill patient
without being clinically recognized.
 Even in the presence of invasive
monitoring, significant cardiovascular
pathologies may be missed. Precise
evaluation of these pathologies is crucial in
CCU specially in critically ill patient
(Bossone et al., 2005).

7.  TTE is helpful in establishing the clinical
diagnosis, in excluding certain clinical
suspicions and in determining what
therapy should be given (Poelaert et al., 1998).
 Because of its rapid, accurate and
repetitive image acquisition, TTE can play
a key role in the diagnosis and evaluation
of patients admitted with acute chest pain
in the ICCU (Orme et al., 2009).

8.  The role of TTE is well known in establishing
the diagnosis, location, and extent of MI, in
diagnosing its mechanical complications and in
providing prognostic information (Horowitz et
al., 1992).
 TTE can be the preferred initial diagnostic
modality when the history, physical
examination, and routine laboratory tests can
not identify the cause of dyspnea (Vannan, 2009).

9.  TTE in the CCU is not only useful for
analyzing cardiac anatomy and function
in critically ill patients, but it can also be
used in evaluating and monitoring the
hemodynamics (Royse et al., 2006).
 TTE can be of great help for adequately
assessing preload and volume status which
important for proper management of
critically ill patients (Michard, 2011).

10. TTE is crucial in CCU specially in
hemodynamically unstable patients for:
Assessment of left ventricular function and
diagnosis of significant RV dysfunction for
guiding resuscitation , informing decisions
management and providing information
about prognosis (Royse et al., 2006).

12. The objective of this study is to
determine the impact of (TTE) on
management decisions and
treatment strategies in patient
admitted to ICCU due to any
cardiovascular problem.

14. Study design
Between January 2010 and October 2010, 100
consecutive patients of either sex in Prince Sultan of
Cardiac Center in Saudi Arabia were included in a
single arm study aiming to assess the role of TTE in the
patients management who were admitted in CCU
under variety of clinical settings.
According to significance of TTE finding in decision
making, the patients were divided into two groups:
Group I, the patients in whom TTE was inconclusive.
Group II, the patients in whom TTE was highly
significant in changing management plan.

15. Methods
All patients were subjected to:
1-Full medical history and physical examination.
2-TTE has done using all possible views to assess:
a. LV diastolic and systolic functions.
b. Wall motion abnormalities.
c. RV systolic pressure using tricuspid velocity.
d. Valve disease and its severity.
e. Presence of intra-cardiac mass.
f. Pericardial effusion and tamponade.
3-Assessment of new intervention within 48 hours
and change of the management.

16. CASE NO. (6)
A 16 years old female admitted in CCU with high fever,
cough, and fatigue. A systolic murmur along the left sternal
border was noted during a routine physical examination.
TTE (2-D mode) showed hyperechogenic mass in the apical
side of RV (1) and in IVS (2).
According to TTE finding, (Cardiac MRI) was planned then
possible surgical resection of intracardiac mass.

18. Table(1):Demographic and baseline characteristics:
Variables Number Percent
Age Mean value 55.58
Standard Deviation 15.939
Sex Male 60 60
Female 40 40
Cause of admission Chest pain 29 29
Congestive symptoms 25 25
Syncope 15 15
Embolic symptoms 15 15
Shock 16 16
Different
co-morbidities
DM 26 26
HTN 21 21
CRF 14 14
Smoking 25 25
Respiratory Diseases 5 5
Cerebrovascular Insuff. 4 4

19. Figure(1): Demographic data according to sex:
Figure(2): Demographic data according cause of admission

20. Table(2): Role of echo according to indication of echo in both groups
INDICATION
OF TTE LVF Valve
lesion RVSP Effusion Mass Total X2 p
Group I (-ve) 5 5 5 5 5 25
Group II (+ve) 40 20 5 5 5 75 14.9 <0.01
Total 45 25 10 10 10 100

21. Table(3): Role of echo according to echo findings:
ECHO
FINDINGS
NOR
MAL
LIMI
TED
LVD Valve
L
Mass
PH P.
EFF. AD HOCM Tota
l X2 p
Group I -ve 15 10 0 0 0 0 0 0 0 25
GroupII +ve 5 0 30 20 5 5 5 2 3 75 80 <0.001
Total 20 10 30 20 5 5 5 2 3 100

22. Table(4): change in management plan in both groups
Change in
Management
Plan
NO
chang
e
Coronary
interven
Valve
surgery
Further
procedure Further
image
Altered
medicati
on
Total X2 p
Group I (-ve) 25 0 0 0 0 0 25
Group II(+ve) 0 23 15 10 11 16 75 100 <0.001
Total 25 23 15 10 11 16 100
Figure(5): change in management plan in both groups

23. Table(5): Significance of echo according to age
N Mean Std. Deviation t p
Group I 25 54.52 15.045
0.4 >0.05
Group II 75 55.93 16.309
Figure(6): Echo significance according to age
56
55.5
55
54.5
54
53.5
54.52
55.93
No Yes

24. Table(6):Significance of echo according to sex
Group I Group II Total
X2 p
No. % No. % No. %
male 20 80.0% 40 53.3% 60 60.0%
female 5 20.0% 35 46.7% 40 40.0% 5.6 <0.05
Total 25 100.0% 75 100.0% 100 100.0%
Figure(7): Echo significance according to sex

26.  TTE plays fundamental role in decision
making and modification in the treatment
strategy in patients who were admitted in
CCU.
 The management plan was changed in 75
out of 100 patients in our study.
 TTE prompts an additional specific
investigations in those patients that have
important influence in their management.

28. All CCU should be provided by portable
echocardiography machines and every
intensivist should have some formal training in
echocardiography.
TTE should be done as early as possible and
can be repeated for further evaluation which
really impact in patient management.

29.  Supportive data for the etiologies of
hypotension and shock can be obtained
rapidly with TTE.
 TEE probe should be available in CCU
however this increases the cost of the
machine and requires experienced
physicians in this field.