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Fall '23 Echo > Aortic Valve Disease Exam #2 > Flashcards

Aortic Valve Disease Exam #2 Flashcards

1
Q

2D and M-mode measurements are good for assessing what in regards to AS?

A

assessing its PRESENCE

NOT

its severity (it is unreliable for severity)

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2
Q

m-mode from SAX to assess AS can be unreliable. True or False do you need to see all 3 cusps or is just 2 ok

A

ALL 3!

also can’t be any wall motion or septal wall abnormalities

lastly, decreased SV can affect cusp separation

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3
Q

TTE Planimetry is unreliable to assess AS as well. Many factors can affect your assessment such as (3)

A
  1. not imaging at max stenosis
  2. not being parallel
  3. heavy calcification, acoustic shadowing, and reverb artifact may obscure cusps
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4
Q

this measurement can ONLY be obtained in cath lab

A

peak to peak av gradient (LV peak pressure and peak aortic pressure)

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5
Q

this measurement is usually lower (by as much as ________mmHg) than the peak instantaneous gradient. *hint its the only measurement that can only be obtained in cath lab

A

30 mmHg!

peak to peak av gradient

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6
Q

4xV2squared solves for what

A

it is the SIMPLIFIED Bernoulli equation used to calculate PEAK INSTANTANEOUS GRADIENT

*use only if LVOT or V1 value is LESS THAN 1.5 m/sec

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7
Q

If the LVOT velocity is greater than OR EQUAL TO 1.5 m/sec, use this equation to solve for PEAK INSTANTANEOUS AV GRADIENT

A

4x (V2 squared - V1 squared)

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8
Q

What pressure constitutes SEVERE AS (give peak gradient value and mean gradient value)

A

peak value is 80mmHg

mean value is 50mmHg

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9
Q

Peak gradient and peak instantaneous gradient are the same thing TRUE OR FALSE

A

TRUE

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10
Q

measures stroke distance

A

velocity time integral

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11
Q

stoke distance is what exactly?

A

it is the distance that the column of blood travels past the LVOT or AoV during one cardiac cycle

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12
Q

why is the continuity equation used? for what type of patients?

A

it is used to calculate AVA or aortic valve area. It is used to calculate AVA instead of peak and mean gradient IN PATIENTS WITH LOW CARDIAC OUTPUT!!!!

mean and peak gradient are not reliable in low cardiac patients

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13
Q

What could cause a low pressure gradient even if a patient had severe AS

A

significant MR could cause AoV peak velocity to be underestimated (one of many things)

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14
Q

With these conditions AI, Anemia, Pregnancy… they could do what and cause an error in what

A

cause an err0r in PG calculation (INCREASE FLOW RATES) across the aorta

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15
Q

continuity equation is effective in calculating what in patients with what? *providing there is no what?

A

calculating effective valve area in low cardiac output state

*providing NO VSD is present!!!

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16
Q

when you are measuring LVOT diameter, make sure you are parallel to what

A

parallel to AORTIC VALVE PLANE

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17
Q

when do you measure the LVOT diameter (what point during cardiac cycle)

A

MID-SYSTOLE

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18
Q

window to view the LVOT should be from where. there are 2

A

apical 5 chamber view and apical long view

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19
Q

what’s the advantage of a non imaging probe

A

higher sensitivity and better access between rib spaces

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20
Q

3 Doppler abnormalities that all occur in ______ that make timing and waveform key to identify when using a non imaging probe

A

aortic stenosis
mitral regurgitation
tricuspid regurgitation

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21
Q

jets mistaken for AS

A

sub aortic obstruction
mitral regurgitation
tricuspid regurgitation
ventricular septal defect
pulmonic artery stenosis
peripheral vascular stenosis

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22
Q

An MR jet is _______in comparison to an AS jet

A

peak velocity is higher (longer duration)
MR usually GREATER than 4 to 5 m/s

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23
Q

the velocity of tricuspid regurgitation usually displays

A

RESPIRATORY VARIATION

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24
Q

Situation: you’re having trouble measuring an LVOT diameter… this is impeding you from obtaining an accurate continuity equation…. what measurement should you use now?

A

DI or dimensionless index
AKA
VELOCITY RATIO

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25
Q

It is INDEPENDENT of CO (measurement)

A

DI
Dimensionless Index
aka
Velocity Ratio

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26
Q

DI =

A

VTILVOT / VTIA

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27
Q

AoV index =

A

AVA/BSA

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28
Q

severity of aortic sclerosis (just memorize moderate… that way anything above is severe and anything below is normal) *these are average calculations

A

(all moderate severity measurements)

peak velocity: 3.0 - 4.0 m/s
mean gradient: 20 - 40 mmHg
ava: 1.0 - 1.5 cm2
indexed ava: 0.60 - 0.85
velocity ratio: 0.25 - 0.50

29
Q

auscultations…
aortic regurgitation is 1.

aortic stenosis is 2.

A
  1. heard at LEFT parasternal border.
    high-pitched diastolic decrescendo blowing murmur
  2. heard at the RIGHT sternal border
    harsh systolic ejection murmur
    may radiate up the carotids
    crescendo-decrescendo in shape
30
Q

AI is

A

AR
Aortic Insufficiency or Aortic Regurgitation

31
Q

this is the most common cause of ao root dilatation in the elderly

A

chronic and poorly controlled HTN

32
Q

what is a complication of AR aka AI?

A

LVVO with LVE
left ventricular volume overload with left ventricular enlargement
left ventricular pressure overload
decreased left ventricular systolic function (if disease has progressed)
increased risk of SBE and veggies

33
Q

Acute AI looks like

A

end diastolic volumes increase but LV can’t dilate rapidly
elevated LA pressure
pulmonary edema
tachycardia
tachycardia caused by increase afterload which leads to decreased stroke volume
myocardial ischemia
premature closure of mv on m-mode and diastolic MR

34
Q

symptoms: dyspnea, lower extremity edema - maybe….?

A

chronic aortic insufficiency

35
Q

surgical intervention for LVDdiastole (mm), LVDsystole (mm), and FS (%)

A

LVDdiastole if greater than 70mm
LVDsystole if greater than 50mm
Fractional shortening if less than 30%

36
Q

the AR jet/LVOT diameter may not be reliable if (2)

A

AI jet is eccentric
AI jet doesn’t have circular cross-sectional shape

37
Q

LVOT area is difficult to trace… you can simplify this with an equation though! easy… just measure the LVOT diameter. then plug in this equation

A

LVOTdiameter squared, then multiply by .785

THAT EQUALS THE LVOT AREA!

38
Q

There must only be a little or no _______ or _______ in order to measure aortic regurgitation volume which is used to grade what

A

little or no MR or subaortic obstruction, used to grade AI severity

39
Q

(formula) regurgitant volume =

A

SVav - SVmv
greater than 60ml indicates severe AI

40
Q

To calculate stroke volume use this formula

A

0.785 x VALVEdiametersquared x VTIofVALVE (pulsed wave, value will be in cm)

answer will be in cc’s so like 152 cc

41
Q

Regurgitant volume and regurgitant fraction are used to measure

A

AI severity

42
Q

(volume) RFav =

A

SVav - SVmv
all divided by
SVav

43
Q

If regurgitant fraction is over ________%, it is severe.

A

50%

44
Q

When measuring PLAX 2-D LVOT diameter, what part of cardiac cycle?

A

mid-systole

45
Q

The optimal imaging view to obtain Doppler of LVOT and AoV is… from how many widows should you obtain Doppler of LVOT/AoV?

A

Apical is optimal view

AO velocities should be obtained from 2 windows… apical, rt parasternal, or suprasternal

46
Q

VELOCITY RATIO

A

The third additional method is using the velocity ratio (also called dimensionless index). This method still measures the effective orifice area (EOA), which is the primary predictor of outcomes.

***VTILVOT divided by VTIAV

47
Q

INDEXED CONTINUITY EQUATION

A

Using the same steps to calculate the AVA using the continuity equation, we can take it a step further to index the AVA by body surface area (BSA). This is beneficial in select patients:

Very large (tall) patients
Very small (petite) patients

AVA / BSA

48
Q

AVA Planimetry

A

Parasternal Short Axis
TEE Preferred
Mid-Systole
Trace minimal orifice area

49
Q

IF THEY OCCUR TOGETHER IN SAME PATIENT the peak _______ is always higher than the peak _______.

A

PEAK MR higher than PEAK AS

50
Q

TR usually has __________ variation…

A

RESPIRATORY!
Remember what is immediately linked to the Right Atrium? The IVC… remember sniff test…? IVC collapses with inspiration etc etc

51
Q

in grading severity of aortic sclerosis, you want these values to be bigger or smaller???

peak velocity?
mean gradient?
ava?
indexed ava?
velocity ratio?

A

peak velocity: smaller the better
mean gradient: smaller the better
ava: bigger the better
indexed ava: bigger the better
velocity ratio: bigger the better

52
Q

The most common cause of ao root dilatation in the elderly is

A

chronic an poorly controlled HTN

53
Q

Acute AI… think “flooding” of the heart… with fluid

A

end diastolic volumes increase/can’t dilate rapidly enough
elevated LA pressure
pulmonary edema
afterload increases which causes decreased SV
tachycardia due to low stroke volume… heart trying to keep up by squeezing faster since it is moving smaller units of blood

54
Q

measure for LVOT area

A

.785 x (LVOTdiametersquared)

use if can’t trace LVOT area

55
Q

if left ventricular diastolic pressure increases

A

a progressive drop in the CW AI velocities will result

56
Q

for pressure half time and deceleration… the steeper the slope, the

A

more severe the AI is!

57
Q

AI slope will be increased and severity of AI will be OVERESTIMATED if CW is

A

NOT within the AI jet throughout diastole

58
Q

SVav - SVmv =

A

regurgitant volume!!!
> 60-65ml indicates severe AI

SVav - SVmv all divided by SVav = your regurgitant fraction which is a percentage answer

> 50% is severe
0-20% is normal

59
Q

in the descending aorta, is it normal for there to be a reversal of flow?

A

yes! due to elastic recoil, small bit of back flow from smaller diameter descending to larger diameter descending

60
Q

One major difference between rheumatic AS and calcific AS in terms of how it affects anatomy

A

Rheumatic AS: commissural fusion is present

Calcific AS: little to NO commissural fusion

61
Q

During an echo exam, it’s important to assess ___________views for AS?

A

ALLLLLL VIEWS!!!!!!

62
Q

When you record patient data such as BP, HR, age, weight, height… its important because any changes in these values affect the correlation to

A

CATH LAB DATA!!!

63
Q

M-mode from SAX can be MORE accurate for assessing AS, but can be unreliable IF:

A

any abnormalities with the walls, only 2 of the 3 cusps are seen, or reduced SV reduces leaflet excursion, or asymmetrical septal hypertrophy

64
Q

peak to peak av gradient vs peak instantaneous gradient… which is lower and why

A

peak to peak av gradient because is lower because it measures the difference between the pressure in the LV vs the pressure across the Aov, can be up to 30mmHg difference between instantaneous and peak to peak av measurements

65
Q

the continuity equation is used to measure AVA since peak and mean gradients are thrown out (unreliable) with

A

LOW CARDIAC OUTPUT PATIENTS

66
Q

Dimensionless Index is a great alternative measurement if you can’t get a good LVOT measurement when doing the continuity equation.. would probably work well for patients with

A

TRICK QUESTION… this measurement is INDEPENDENT OF CARDIAC OUTPUT!!!! :)

67
Q

AR Jet Diameter to LVOT Diameter ratio

mild?
moderate?
severe?

A

mild <30%
moderate 30-50%
>50% severe

68
Q

To grade AI severity… divide what

A

AR jet area/LVOT area

bc LVOT can be difficult to trace, measure LVOT diameter, then square it and multiply it by .785

That’s your LVOT area.

69
Q
A

Fall '23 Echo (19 decks)

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