Ch 14 Normal Doppler Patterns Flashcards
How do we take a Vmax measurement?
Place a caliper at the highest velocity (peak) of a spectral waveform to measure the max velocity
What other measurement may also be generated after a Vmax is done?
A maximum instantaneous pressure gradient
What does VTI stand for?
Velocity time integral
How can we take measurements of changing velocities over a period of flow?
By tracing the outline of the specific spectral doppler waveform of interest (called a VTI)
What do VTI measurements represent?
-Velocity (cm/s or m/s) vs time
-Meaning the tracing represents the distance measured flow has traveled (cm)
(think of VTI as stroke distance)
A VTI can be thought of as “stroke distance”, what does this mean?
Is the distance a column of blood travels with each heartbeat
The result of a VTI is the appearance of what 3 things?
-Vmax velocity
-Max instantaneous pressure gradient
-Mean instantaneous pressure gradient (obtained at regular intervals throughout the period of flow)
How do we obtain a PW of the LV inflow (MV)?
-Done in AP4 (b/c of parallel alignment)
-PW sample volume box placed centrally at tips of MV leaflets, on the LV side of valve
How will flow appear on the PW tracing of MV inflow?
Flow is antegrade, appearing above the baseline in diastole
What are we able to visualize + quantify from doing a PW of the MV inflow?
Allows visualization + quantification of the movement of blood from LA to LV in diastole
What does the Vmax caliper of the E wave velocity represent? What part of the ECG does it correlate with?
-Early diastolic filling (80%)
-After T wave on ECG
What does the Vmax caliper of the A wave velocity represent? What part of the ECG does it correlate with?
-Late diastolic filling after atrial contraction (20%)
-After P wave on ECG
What is the E/A slope (aka deceleration time)?
Time b/w peak E velocity + point of deceleration to the baseline in ms
What is the E/A ratio?
Generated after completion of measurements + allows evaluation of diastolic dysfunction
What is the normal range for Peak E (m/s)?
0.46-1.12
What is the normal range for Peak A (m/s)?
0.35-0.98
What is the normal range for deceleration time (m/s)?
112.8-296.4
What is the normal range for E/A ratio?
0.64-2.74
What are the E/A ratio + E wave basic expectations for normal young healthy adults?
-E/A ratio >1
-E wave of approx 1 m/s or greater
(E wave normally bigger than A wave)
MV inflow changes with aging due to what?
The LV becoming less compliant + more stiff
What happens to the E/A ratio as people age?
The A wave increases in size compared to the E wave - b/c LV is harder to fill, a stronger atrial kick is required
List 4 changes to MV inflow due to aging?
-Reduction in E velocity
-Prolongation of early diastolic deceleration
-Increase in A velocity
-E/A ratio of <1
What is grade 1 impaired relaxation of MV inflow?
Normal age related change causing A wave to be bigger than E wave
List 4 pitfalls when using PW over the LV infow (MV)?
-Not being truly parallel to flow (watch where flow is going)
-Sample volume size (3mm is ideal, larger will lead to spectral broadening)
-Sample volume placement (placing SVB too high/low leads to different appearances of waveforms)
-High HRs can lead to E/A wave fusion (increase sweep speed to see waveforms)
What is the typical SVB size we use?
3mm (avoid making larger + causing spectral broadening)
If a pt has a high HR of 120 during an exam, should we continue using doppler in the exam?
-Dopplers are considered undiagnostic now
-Some labs recommend not measuring in these cases
How do we use tissue doppler + PW on the medial/lateral MV annulus?
-Done in AP4 (ensure beam remains parallel as possible to myocardial motion throughout heartbeat)
-Activate TDI imaging
-PV SVB placed at fibrous MV annulus (medial/septal + lateral)
How will myocardial motion be displayed above + below the baseline with tissue doppler?
-Above the baseline as systolic motion
-Below the baseline as diastolic motion
Explain what S’, E’ and A’ are in tissue doppler?
S’: Apically directed systolic myocardial velocity
E’: Early diastolic atrially directed myocardial velocity (after T wave)
A’: Late diastolic atrially directed myocardial velocity
What 3 measurements are routinely done with tissue doppler of medial/lateral MV annulus?
-Vmax caliper of E’ medial/septal
-Vmax caliper of E’ lateral (should be higher than medial/septal in normal pt)
-E/E’ (ratio comparing E wave from MV inflow to E’ from TDI annular motion)
(allows for evaluation of diastolic dysfunction)
Why does E’ lateral have a higher Vmax than E’ medial/septal in TDI?
B/c lateral side is a free wall, it has much more room to move. The medial/septal side is tethered into the IVS, preventing it from moving as much.
What is the normal range for septal E’ (cm/s)?
5.0-17.0
What is the normal range for lateral E’ (cm/s)?
6.0-22.0
(remember is higher than septal b/c is a free wall)
How to obtain PW over the pulmonary veins?
-Done in AP4
-Place PW SVB 0.5-1.0cm into the RUPV/RLPV (NOT at the back of the LA)
(RUPV = RSPV, RLPV = RIPV)
PW on the pulmonary veins demonstrate biphasic flow, what does this mean?
-Systolic + diastolic forward flow is antegrade
-Atrial flow reversal is retrograde
Systolic forward flow of the pulmonary veins occurs due to what? What part of the ECG does this correlate with?
-Due to LA relaxation + movement of MV annulus towards LV apex in systole
-Is closely related to LA pressures
-Aligns with T wave on ECG
Diastolic forward flow of the pulmonary veins occurs due to what? What part of the ECG does this correlate with?
-Due to the open conduit b/w the PVs, LA, open MV + LV
-Parallels MV E wave + DT (deceleration time)
-Occurs after T wave on ECG
Atrial flow reversal of the pulmonary veins occurs due to what? What part of the ECG does this correlate with?
-Due to retrograde flow into the PVs following atrial contraction/kick
-Small volume of blood gets pushed backwards
-Occurs after P wave on ECG
Explain what S, D and AR is on PW tracing of the PVs?
S: systolic forward flow
D: diastolic forward flow
AR: atrial reversal
What 4 measurements are done on a PW tracing of the PVs?
-Vmax S
-Vmax D
-Vmax AR
-S/D ratio (compares flow velocities from systolic + diastolic components)
(allows for evaluation of diastolic dysfunction + LV end-diastolic pressures)
How is PW obtained of the LVOT?
-Done in AP5 (possible to angle view so LVOT/AO is more parallel than standard view)
-Place PW SVB centrally within LVOT b/w 0.5-1.0cm from AoV
How does flow appear on the PW tracing of the LVOT?
Monophasic + retrograde = flow results below the baseline
What can we visualize + quantify on a PW tracing of the LVOT?
Allows visualization + quantification of movement of blood through LVOT on the way to the AoV in systole
Measurements in the LVOT allow for calculation of what 5 things?
-Stroke volume
-Cardiac output
-Regurgitant volumes
-Shunt ratios
-Valve areas
What measurement is routinely done of the LVOT on a PW tracing?
A VTI trace of the LVOT from opening click to closing click
(known as V1 in the AVA continuity equation)
List 4 measurements obtained after a VTI of the LVOT on a PW tracing?
-LVOT Vmax
-LVOT max pressure gradient
-LVOT mean pressure gradient
-LVOT VTI
What is the normal range for a Vmax of the LVOT?
0.8-1.2 m/s
What is the normal range for a VTI of the LVOT?
18-22 cm
How can we obtain a CW tracing of the AoV outflow?
-Done in AP5 routinely, can angle view so the Ao/AoV is more parallel than standard view (can use AP3 too)
-CW cursor line placed centrally through AoV
How will the flow appear on the CW tracing of the AoV outflow?
Monophasic + retrograde = resulting in flow below the baseline
What are we able to visualize + quantify from doing a CW tracing of the AoV outflow?
Allows visualization + quantification of the movement of blood from LV, LVOT + AoV
(seeing the opening/closing slicks + possibly outline of LVOT ensures we have the most optimal tracing)
What is the normal range for a Vmax of the AoV outflow?
1.0-1.7 m/s
What is the normal range for a VTI of the AoV outflow?
18-26 cm
What measurement is routinely done of the AoV outflow on a CW tracing?
A VTI trace of the AoV from opening click to closing click
(known as V2 in the AVA continuity equation)
List 4 measurements obtained after a VTI of the AoV outflow on a CW tracing?
-AoV Vmax
-AoV max pressure gradient
-AoV mean pressure griadient
-AoV VTI
List 4 doppler LVOT + AoV pitfalls?
-Not being truly parallel to flow
-Sample volume/cursor line placement (placing SVB too high/low affects waveforms + placing cursor line too close to the walls of the AO can cause artifacts)
-Not trimming the beard (adjust doppler gains to remove excess wispy signals + ensure we are tracing the chin, not the beard)
-Not tracing to/ending at the closing click
How can we accurately “trim the beard”?
Trim it to what is consistently true in the tracing. We do not care about the excess wispy signals (the beard), only the hyperechoic waveform (the chin). Must ONLY trace the chin + exclude the beard.
How can we obtain a PW/CW tracing of the descending thoracic aortic flow?
-Done from SSN window
-Routinely place PW SVB 1cm below origin of left subclavian artery
-Can additionally place CW cursor line centrally within descending AO parallel to flow (depending on area of interest)
What is the normal Vmax range for descending thoracic aortic flow?
<1.5 m/s
Waveforms of the descending thoracic aortic flow + the proximal abdominal aorta flow is often simply shown to differentiate what 2 things?
Normal vs abnormal:
-Determined by variance in flow pattern seen in color + spectral doppler
-Do Vmax if quantification is necessary
List 3 ways the typical flow of the descending thoracic aorta appears on tracings?
-Primarily non turbulent flow
-Systolic retrograde flow
-Followed by small amounts of diastolic flow reversal
How to obtain a PW tracing of the abdominal aorta?
-Done from subcostal abdominal aorta view
-Place PW SVB within center of aorta (typically an area with sufficient color appreciation)
-Is pulsatile flow
List 3 ways the typical flow of the proximal abdominal aorta appears on tracings?
-Normal antegrade flow during systole
-Followed by brief early diastolic flow reversal
-Slight antegrade flow in mid diastole
Is PW a routinely performed interrogation on the RV inflow?
No
How can we obtain PW on the RV inflow?
-Done in AP4
-Place PW SVB centrally at tips of TV leaflets, on the RV side of the valve
How does flow appear on the PW tracing of the RV inflow?
Flow is antegrade = above the baseline
What are we able to visualize + quantify from doing a PW tracing of the RV inflow?
Allows visualization + quantification of the movement of blood from RA to RV in diastole
The RV inflow has lower velocities when compared to the LV inflow, what is this due to?
Lower pressures of the right side of the heart
(TV waveforms will have softer waveforms + lower velocities will be seen)
Are measurements of the RV inflow typically done?
No, but it is important to understand the options available
Explain where the E and A waves appear on the ECG with RV inflow?
E: After T wave
A: After P wave
List 4 measurement options for RV inflow?
-Vmax caliper of E wave velocity
-Vmax caliper of A wave velocity
-E/A slope (deceleration time)
-E/A ratio
RV inflow normal ranges vary with age + with respiration. Why does respiration effect this?
B/c inspiration causes slight increase in E + A velocities. However, they increase equally so there is no change to the E/A ratio.
How to obtain tissue doppler of lateral TV annulus?
-Done in AP4
-Activate TDI
-Place PW SVB at lateral fibrous TV annulus
How will myocardial motion be displayed on the tissue doppler tracing of the lateral TV annulus?
-Below baseline as diastolic motion
-Above baseline as systolic motion
What is the normal tissue doppler range for the lateral TV annulus?
> 10 cm/s
Is the CD scale with TDI a lot higher or lower than CW + PW?
Lower
What measurement is routinely measured when doing a tissue doppler of the lateral TV annulus?
Vmax caliper S’ lateral - is used along with TAPSE to decipher RV systolic function
How to obtain a PW tracing of the RVOT?
-Done in PSAX AoV level
-Place PW SVB centrally within RVOT 0.5-1.0cm from the PV
How does flow of the RVOT appear on a PW tracing?
Monophasic + retrograde = below the baseline
What are we able to visualize + quantify from doing a PW of the RVOT?
Allows visualization + quantification of the movement of blood through the RVOT, on the way to the PV in systole
RVOT measurements allow for calculation of what 2 things?
-Mean pulmonary artery pressure
-Shunt ratios
RVOT + LVOT have similar flow profiles, what are the differences?
-RVOT has slower velocities + a more rounded curve
-Low resistance of pulmonary vasculature results in a slower rate of acceleration of flow
-RVOT waveform is wider than LVOT
List 4 measurements obtained after a VTI of the RVOT on a PW tracing?
-RVOT Vmax
-RVOT max pressure gradient
-RVOT mean pressure gradient
-RVOT VTI
What is routinely measured of the RVOT on a PW tracing?
-VTI trace of RVOT (we do in lab)
or
-Vmax of RVOT (dependent on lab preference)
What is the normal RVOT VTI range?
14-16 cm
What is the normal RVOT Vmax range?
0.7-1.0 m/s
How to obtain a CW tracing of the PV?
-Done in PSAX AoV level
-Place CW cursor line centrally through PV
How does PV flow appear on a CW tracing?
Monophasic + retrograde = below baseline
What are we able to visualize + quantify from doing a CW tracing of the PV?
Allows visualization + quantification of the movement of blood from RV, RVOT + PV
What is the normal PV Vmax range?
0.7-1.4 m/s
(suspicious of PV stenosis if over 1.4 m/s)
What is routinely measured of the PV on a CW tracing?
-VTI trace of PV (we do in lab)
or
-Vmax of PV (dependent on lab preference)
List 4 measurements obtained after a VTI of the PV on a CW tracing?
-PV Vmax
-PV max pressure gradient
-PV mean pressure gradient
-PV VTI
How to obtain PW tracing of right atrial filling (hepatic vein)?
-Done in subcostal IVC/Hep view
-Place PW SVB 1-2 cm into HV
Flow is continuous throughout the cardiac cycle, list the 4 phases of flow we see with right atrial filling?
-Systole forward flow
-Ventricular (systolic) flow reversal
-Diastolic forward flow
-Atrial reversal flow
Explain how the S wave, D wave, A wave and VR wave appears in regards to the baseline in a PW tracing of right atrial filling? What type of flow does each wave have?
S wave: below baseline + systolic forward flow
D wave: below baseline + diastolic forward flow
A wave (AR wave): above baseline + atrial flow reversal
VR wave: above baseline + ventricular flow reversal
Systolic forward flow with RA filling occurs due to what?
RA relaxation + movement of TV annulus towards RV apex in systole
Diastolic forward flow with RA filling occurs due to what?
Due to the open conduit b/w HV, RA, open TV + RV
Atrial flow reversal with RA filling occurs due to what?
Happens from retrograde flow into the HV following atrial contraction/kick
(small volume of blood gets pushed backwards)
Ventricular flow reversal with RA filling occurs due to what?
From retrograde flow into the HV occurring in late systole
(is lower than AR velocities)
Does inspiration increase the S, D, AR or VR wave?
S + D waves
Does expiration increase the S, D, AR or VR wave?
AR + VR waves
Are measurements typically performed in the PW tracing of the RA filling?
No, waveform is simply just shown
(but could take a Vmax of the S, D, AR + VR wave velocities at inspiration + expiration)
In the presence of Afib, how many times should we measure each doppler waveform?
3 times to create an average
Should we measure arrhythmic waveforms?
No! They are not representative of the overall rhythm, utilize normal ones a beat or 2 away
Should we use CD before applying spectral doppler?
Yes! Always
How can utilizing doppler gain to “trim the beard” of spectral doppler waveforms help us?
Ensures we are measuring the waveforms “chin” + not the waveforms “beard”
Is spectral doppler optimization important for accurate measurements?
Yes! Always ensure we have full/complete envelopes through optimizing + ensuring our angle is parallel to flow
Which 2 structures do we only use CW with?
-AoV outflow
-PV
(can be additionally used with the descending thoracic Ao, but typically PW is used)
