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PHYSL 404 - Cardiovascular Physiology > 16 - Myocardial Remodeling > Flashcards

16 - Myocardial Remodeling Flashcards

1
Q

Define myocardial remodeling

A

Alteration in the structure (dimensions, mass, shape) of the heart in response to hemodynamic load and/or cardiac injury

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2
Q

What are three underlying components of myocardial remodeling?

A
  1. Neurohormonal activation
  2. Gene expression
  3. Signaling pathway activation
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3
Q

What are conditions that lead to remodeling of the heart and hypertrophy (increased growth of muscle cells)

  • Atrophy caused by:
  • Physiologic hypertrophy:
  • Pathologic hypertrophy:
A
  • Atrophy
    • Bed rest, ventricular assist device, cancer, and weightlessness
  • Physiologic hypertrophy
    • Exercise pregnancy
  • Pathologic hypertrophy
    • Hypertension, myocardial infarction, and neurohumoral activation
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4
Q

Fill in the image:

A
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5
Q

What is LVAD?

A

Left ventricular assist device

  • connected to the heart
    • pumps blood into the aorta
    • Blood from left ventricle enters the LVAD
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6
Q

What are treatment options for pathological myocardial remodeling?

A

Surgical Tx

Medical Tx

Device Tx

  • improved LV function*
  • reduced LV size*
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7
Q

Label the types of left ventricular remodeling:

A
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8
Q

LV Concentric hypertrophy caused by ______

A

Concentric hypertrophy caused by pressure overload

eg: hypertension, aortic valve stenosis, hypertrophic cardiomyopathy

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9
Q

LV eccentric remodeling dilation caused by _______

A

LV eccentric remodeling dilation caused by Volume-overload

eg: Valvular regurgitation,

post-MI

Prolonged pressure-overload

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10
Q

Label the image

A
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11
Q

What is the modified Law of Laplace as it applies to dilated cardiomyopathy

A

Wall stress = LV pressure (P) x Radius (R) / 2 x wall thickness (T)

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12
Q

Draw how the pressure-volume loop changes with Left ventricular hypertrophy

A
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13
Q

Draw how the pressure-volume loop changes with dilated cardiomyopathy

A
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14
Q

Myocardial infarction triggers what sequence of events?

A
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15
Q

Systolic dysfunction:

  • impaired ________ during _____
  • Reduced ______
  • If untreated, advances to _______
A

Systolic dysfunction:

  • impaired pumping function of the LV during systole
  • Reduced contractility (↓ejection fraction, ↓stroke volume)
  • If untreated, advances to systolic heart failure or HF with Reduced Ejection Fraction (HFREF)
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16
Q

Diastolic dysfunction:

  • Decline in performance of _______
  • Impaired _______
  • If untreated, advances to _______
A

Diastolic dysfunction:

  • Decline in performance of the ventricle during diastole
  • Impaired relaxation or filling capacity
  • If untreated, advances to diastolic heart failure or HF with preserved Ejection Fraction (HFPEF)
  • can occur with or independent from systolic dysfunction
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17
Q

Ventricular remodeling after infarction leads to _______

A

Ventricular remodeling after infarction leads to systolic heart failure

or HF with reduced ejection fraction (HFrEF)

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18
Q

How does Ventricular remodeling after infarction lead to systolic heart failure

or HF with reduced ejection fraction (HFrEF)

A
  1. At time of acute myocardial infarction - in the image = apical infarction - there is no clinically significant change in overall ventricular geometry
  2. Within hours to days, the area of myocardium affected begins to expand and become thinner
  3. Within days to months, global remodeling can occur - resulting in overall ventricular dialation, decreased systolic function and mitral-valve dysfunction
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19
Q

The classic ventricular remodeling that occurs with hypertensive heart disease results in a normal-sized ________ with _________ and preserved _____ function. There may be some thickening of the __________

Hypertrophied heart (_______ heart failure)

A

The classic ventricular remodeling that occurs with hypertensive heart disease results in a normal-sized left ventricular cavity with thickened ventricular walls (concentric LVH) and preserved systolic function. There may be some thickening of the mitral-valve cusps.

Hypertrophied heart (diastolic heart failure)

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20
Q

the classic remodeling that occurs with dilated cardiomyopathy results in a _____ shape of the heart, a thinning of the _________\_, an overall decrease in ____\_ function, and distortion of the _________\_ apparatus, leading to MR.

Dilated heart = _____ heart failure

A

the classic remodeling that occurs with dilated cardiomyopathy results in a globular shape of the heart, a thinning of the left ventricular walls (eccentric LVH), an overall decrease in systolic function, and distortion of the mitral-valve apparatus, leading to MR (mitral valve regurgitation).

Dilated heart = systolic heart failure

21
Q

What is the doppler echocardiographic imagin (trans-thoracic ultrasound) used for?

A

Used to measure the architecture and contractility of the heart chambers (RV, LV, RA,LA)

21
Q

What is the doppler echocardiographic imagin (trans-thoracic ultrasound) used for?

A

Used to measure the architecture and contractility of the heart chambers (RV, LV, RA,LA)

22
Q
  • An echocardiogram uses _______________\_ to create an image of the heart (a single beam of ultrasound is used).
  • _______________\_ allows determination of the speed and direction of blood flow by utilizing the ________
A
  • An echocardiogram uses high frequency sound waves to create an image of the heart (a single beam of ultrasound is used).
  • Doppler technology allows determination of the speed and direction of blood flow by utilizing the Doppler Effect.
23
Q

Doppler technology allows determination of the ________ by utilizing the ________

A

Doppler technology allows determination of the speed and direction of blood flow by utilizing the Doppler Effect

24
Q

What is B-mode echocardiogram vs M-mode echocardiogram?

A
  • B-mode (short axis view)
    • LV cross-section
    • 2D analysis
    • Assesses LV contraction
    • no time axis
  • M-mode
    • 1D analysis
    • Movement of LV wall during contraction and relaxation over time
25
Q

Label the image about information obtained from B-mode and M-mode images

A

B-mode shows increased wall thickness of LV chamber

M-mode shows increased LV dilation

26
Q

What two parameters are used to assess systolic function?

A
  • Fractional shortening
    • Fraction of the diastolic dimension lost in systole (expressed as a percentage)
  • Ejection Fraction
    • Fraction of the end-diastolic volume pumped out of the LV (or RV) with each contraction. Expressed as percentage
27
Q

What is fractional shortening and how is it calculated?

A
  • parameter used to assess systolic function
  • Fraction of the diastolic dimension lost in systole

LVEDD = left ventricular end-diastolic diameter

LVESD = Left ventricular end-systolic diameter

28
Q

What is Ejection Fraction and how is it calculated?

A
  • Parameter used to assess systolic function
  • Fraction of the end-diastolic volume pumped out of the LV (or RV) with each contraction. Expressed as percentage.

LVEDv = left ventricular end-diastolic volume

LVESv = Left ventricular end-systolic volume

29
Q

What are the three phases of Diastole?

A
  • Isovolumetric relaxation
    • Semilunar valves close
    • AV valves remain closed
  • Passive early ventricular filling
    • AV valves open, blood flows into the relaxed ventricles (accounts for most of the filling)
  • Active ventricular filling
    • Atria contract and complete ventricular filling
30
Q

Parameters to assess diastolic function:

  • Based on ______ through the mitral valve
    • Waves:
A

Parameters to assess diastolic function:

  • Based on blood flow through the mitral valve
    • Waves:
      • E-wave - transmitral flow velocity during early/passive ventricular filling
      • A-wave - transmitral flow velocity during atrial conctraction (active filling)
31
Q

What are E and A waves and how are they used to assess diastolic function?

A

Based on blood flow through the Mitral valve:

  • E-wave – Transmitral flow velocity during early/passive ventricular filling
  • A-wave – Transmitral flow velocity during atrial contraction (active filling).
32
Q

What do the E and A waves show in the image?

A
  1. Normal physiology
  2. impaired relaxation
  3. Restrictive physiology
33
Q

What two Tissue Doppler parameters are used to assess diastolic function? What are they based on?

A
  • Tissue Doppler parameters
  • Based on movement of tissue, Mitral annulus velocity:
    • e’-wave – Tissue Doppler velocity at the mitral annulus level during early filling.
    • a’-wave – Tissue Doppler velocity at the mitral annulus level during atrial contraction.
34
Q

What is e’ wave?

A
  • Parameter to assess diastolic function
  • Mitral annulus velocity:
    • e’-wave – Tissue Doppler velocity at the mitral annulus level during early filling.
    • a’-wave – Tissue Doppler velocity at the mitral annulus level during atrial contraction.
35
Q

What is the a’ wave?

A
  • Mitral annulus velocity:
    • e’-wave – Tissue Doppler velocity at the mitral annulus level during early filling.
    • a’-wave – Tissue Doppler velocity at the mitral annulus level during atrial contraction.
36
Q

Label the types of diastolic dysfunction based on the Mitral Flow Velocity and Mitral Annulus Velocity

A
37
Q

Which Diastolic Dysfunction type shows:

  • Reversal of E/A (and e’/a’) ratio
  • often no clinical signs of HF
  • Mildest form DD
A

Degree 1 (DD degree one) = delayed relaxation

  • Reversal of E/A (and e’/a’) ratio
  • often no clinical signs of HF
  • Mildest form DD
38
Q

What type of Diastolic Dysfunction shows

  • Psuedonormalization filling dynamics
  • Elevated LA filling pressure (↑ A-Wave)
  • ↓e’ ; ↓a’ ; ↓ e’/a’
  • associated with LA enlargement and symptoms of HF
A

Pseudonormal Diastolic dysfunction (DD degree II)

39
Q

What type of diastolic dysfunction is associated with

  • Restrictive filling dynamics
  • ↓e’, ↓a’
  • Advanced HF symptoms (enlarged LA, often ↓EF, poor prognosis)
A

Degree III and IV, severe diastolic dysfunction.

  • Restrictive filling dynamics
  • ↓e’, ↓a’
  • Advanced HF symptoms (enlarged LA, often ↓EF, poor prognosis)
40
Q

How to recognize Degree III and IV Diastolic dysfunction

A

Degree III and IV, severe diastolic dysfunction.

  • Restrictive filling dynamics
  • ↓e’, ↓a’
  • Advanced HF symptoms (enlarged LA, often ↓EF, poor prognosis)
41
Q

How to recognize Degree 1 Disastolic dysfunction

A

Degree 1 (DD degree one) = delayed relaxation

  • Reversal of E/A (and e’/a’) ratio
  • often no clinical signs of HF
  • Mildest form DD
42
Q

How to recognize Degree II diastolic dysfunction

A
  • Psuedonormalization filling dynamics
  • Elevated LA filling pressure (↑ A-Wave)
  • ↓e’ ; ↓a’ ; ↓ e’/a’
  • associated with LA enlargement and symptoms of HF
43
Q

Label the type of diastolic dysfunction:

A
44
Q

What are two additional parameters to assess diastolic dysfunction (aside from E/A ; e’/a’)

A
  • Isovolumetric Relaxation Time (IVRT)
    • ↑IVRT = diastolic dysfunction
  • Decceleration Time (DT)
    • ↑DT = diastolic dysfunction
45
Q

What is DT?

A

Decceleration time

Time from peak E wave to baseline

46
Q

What is the Tei index?

A

Index of myocardial performance that evaluates LV systolic and diastolic function in combination (not just diastolic function)

47
Q

How do you calculate Tei index?

A

Tei index = (ICT + IRT) / ET

=(a-b)/b

ICT = isovolumic contraction time

IRT - IRTV = isovolumic relaxation time

ET = ejection time

48
Q

Fill in the summary table of Echo parameters used to diagnose diastolic dysfunction

A

PHYSL 404 - Cardiovascular Physiology (17 decks)

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