Ch 9 Apical Measurements

Question 1

What is the preferred method for 2D volume calculations, particularly LV EF + LA volume?

Answer 1

Biplane method of discs (modified simpson’s rule)

Question 2

What is the biplane method of discs (modified simpson’s rule)?

Answer 2

Calculates ventricular volumes as a sum of a series of parallel slices (called discs) from the apex to base

Question 3

List 2 advantages of using Simpson’s biplane method?

Answer 3

-2 planes of measurements give fewer assumptions about ventricular shape

-Changes in ventricular geometry caused by pathology won’t effect our accurate measurement of EF

(pathology such as Ao stenosis, volume overload + wall motion abnormalities due to MI or CAD)

Question 4

Which views do we perform Simpson’s biplane measurements?

Answer 4

Zoomed up image of LV in AP4 + AP4

Question 5

How do we get an EF by using Simpson’s biplane?

Answer 5

-By tracing the endocardial borders at end diastole + end systole
-Gives us an EF for AP4/AP2 + most importantly a biplane EF for both

Question 6

List the 5 steps to perform a Simpson’s biplane measurement?

Answer 6

-Decrease depth + focus image on LV
-Place + set cursor on MV annulus
-Trace blood/tissue interface along endocardial border
-Place last cursor on lateral side of MV annulus
-Connect LV length line from MV annulus to apex of LV

Question 7

Should AP4 + AP2 have very similar EFs?

Answer 7

Yes!

Question 8

What is the normal range for end diastolic volume?

Answer 8

Women: 46-106 mL
Men: 62-150 mL

(males are larger b/c they have a bigger heart)

Question 9

What is the normal range for end systolic volume?

Answer 9

Women: 14-42 mL
Men: 21-61 mL

Question 10

What is the m/c used measurement for cardiac function?

Answer 10

LV EF

(EF = % of blood leaving heart during each contraction)

Question 11

Formula for EF?

Answer 11

EF = (EDV - ESV) / EDV x 100

(this is the simplified version we use, the Simpson’s version is very complex)

Question 12

Normal EF range?

Answer 12

Women: 54-74%
Men: 52-72%

Question 13

How do we acquire a LA volume measurement?

Answer 13

-Measured at end systole in zoomed in AP4 + AP2
-Trace blood/tissue interface (endocardium) of LA
-Set first caliper under MV annulus, trace internal perimeter of LA + set second caliper under opposing annular side
-Adjust length line to be perpendicular to MV annulus, along length of LA

Question 14

Upper normal limit for LA volume is what in men/women?

Answer 14

Men/women: 34 mL/m^2

Question 15

List the ranges for a midly enlarged, moderately enlarged + severly enlarged LA volume in men/women?

Answer 15

Mild: 35-41 mL/m^2

Moderate: 42-48 mL/m^2

Severe: > 48 mL/m^2

Question 16

Is LA volume indexed to BSA or gender?

Answer 16

BSA

Question 17

What are some pathologies that could cause left atrial enlargement?

Answer 17

MV regurgitation

Question 18

List 4 ways we can optimize our 2D image for best endocardial definition when we are going to do a Simpson’s biplane measurement?

Answer 18

-Gains
-Color maps/chroma maps
-Harmonics
-Dynamic range

Question 19

Should pap muscles + trabeculations be ignored or included when doing a Simpson’s biplane measurement?

Answer 19

Ignored! Similar to how they are ignored in 2D linear measurements

(trace past the pap muscles b/c they are not the true LV wall + only exist in one plane)

Question 20

How can we avoid LV shortening?

Answer 20

Drop down rib space or go more lateral if we are shortening the LV

Question 21

Do diastole + systole measurements in AP4 + AP2 need to be performed in the same beat?

Answer 21

Yes!

Question 22

LV length is perpendicular to what when doing a Simpson’s biplane measurement?

Answer 22

Base width - measured from center of MV annulus to LV apex

Question 23

The length line variability b/w AP4 + AP2 should be what when doing a Simpson’s biplane?

Answer 23

<10%

Question 24

Should the apex move much b/w diastole + systole when doing Simpson’s biplane measurements?

Answer 24

No!

Question 25

EF variability b/w AP4 + AP2 should be within how many percentage points of each other when doing Simpson's biplane measurements?

Answer 25

Within a few percentage points, unless WMAs are present

Question 26

Are we allowed to "fudge" data when doing a Simpson's biplane measurement?

Answer 26

NO, must get the entire LV in the sector and do it correctly. These are some of the most important images we take during an echo.

Question 27

If we are foreshortening the LA, similar to the LV, how can we fix this?

Answer 27

-Drop down a rib space -Angle slightly superior/inferior to ensure largest volume is assessed

Question 28

The LA length is perpendicular to what structure when taking a left atrial volume measurement?

Answer 28

Perpendicular to the MV annular plane

Question 29

Variability b/w AP4 + AP2 for left atrial volume measurements is what?

Answer 29

<5mm

Question 30

LA length is measured from what 2 points when taking a LA volume measurement?

Answer 30

-From mid point of MV annulus -To mid point of superior wall

Question 31

Should we include the LA appendage or PVs in our LA volume measurement?

Answer 31

NO!

Question 32

What happens if the LA length is not measured perpendicular to the MV annular plane when taking a LA volume measurement?

Answer 32

It creates a region of dead space, underestimating the true LA volume

Question 33

What happens if the LA is foreshortened + the LA length is not perpendicular to MV annular plane when taking a LA volume?

Answer 33

It creates 2 areas of dead space that is not calculated in the LA volume, therefore underestimating the true LA volume

Question 34

What happens if we include a PV into our LA volume?

Answer 34

We will overestimate the size of the LA

Question 35

When are the RA linear measurements done? What view are they done in?

Answer 35

-End systole -AP4 (think any measurements of the atria are always done in systole)

Question 36

How do we take an RA major dimension?

Answer 36

Measure length of atria from superior to inferior

Question 37

How do we take an RA minor dimension?

Answer 37

Measure width from lateral RA wall to IAS at the mid atrial level (defined by half of the RA long axis/length)

Question 38

What is the normal RA major dimension range?

Answer 38

Less than 5.3 cm

Question 39

What is the normal RA minor dimension range?

Answer 39

Less than 4.4 cm

Question 40

How to do an RA volume tracing?

Answer 40

-Perform in AP4 -Trace blood/tissue interface (endocardium) -Start under TV annulus -RA length done at center of area under the TV annulus to the superior RA wall -RA length is perpendicular to TV annular plane (currently the ASE recommended way to quantify RA volume)

Question 41

Why is the RA volume not a biplane measurement?

Answer 41

B/c we don't have a verified second plane for the RA (is technically more of an area than a volume)

Question 42

What is the RA volume abnormal cut off in men + women?

Answer 42

Women: > 33 mL/m^2 Men: >39 mL/m^2

Question 43

If we can not visualize a structure that well, should we still measure it to get some data?

Answer 43

No, no data is better than wrong data

Question 44

What does TAPSE stand for?

Answer 44

Tricuspid annular plane systolic excursion

Question 45

What does TAPSE assess?

Answer 45

Quantification of RV systolic function (it is used in tandem with other measurements to create a complete clinical picture)

Question 46

In which view is TAPSE typically performed in?

Answer 46

AP4 usually, can be done in MOD AP4 depending on visibility + angulation to m-mode cursor

Question 47

Where is the m-mode cursor placed when doing TAPSE?

Answer 47

-Placed through the anterior TV annulus -In line with the plane in which the annulus will move most PERPENDICULAR to the cursor throughout the cardiac cycle

Question 48

Which part of the TAPSE tracing is measured?

Answer 48

The brightest/most continuous line is measured (via slope or inferior/superior length)

Question 49

Which part of the cardiac cycle is the TAPSE measurement done in?

Answer 49

-From end diastole to end systole -Begins at R wave on ECG

Question 50

What is the TAPSE normal range?

Answer 50

>1.7cm or 17mm

Question 51

In which view is the RVD1 + RVD2 measurements taken in? What part of the cardiac cycle?

Answer 51

MOD AP4 at end diastole

Question 52

Where is the RVD1/RVIDd measurement taken?

Answer 52

Basal 1/3 of the RV (also called RV basal dimension)

Question 53

Where is the RVD2 measurement taken?

Answer 53

Middle 1/3 of the RV, at the level of the pap muscles (also called RV mid dimension)

Question 54

Are the RVD1 + RVD2 measurements done inner to inner or outer to outer?

Answer 54

Inner to inner edge + parallel to TV annulus

Question 55

Does the RV apex need to be seen when doing RVD1 + RVD2 measurements?

Answer 55

Yes

Question 56

Do we do the RVD1 or RVD2 measurement in lab?

Answer 56

RVD1/RVIDd

Question 57

What is the normal range for RV chamber size in RVD1?

Answer 57

2.5 - 4.1 cm (RVD1 = RV basal diameter)

Question 58

What is the normal range for RV chamber size in RVD2?

Answer 58

1.9 - 3.5 cm (RVD2 = RV mid diameter)

Question 59

What does "FAC" stand for?

Answer 59

Fractional area change (think RV systolic function)

Question 60

In which view is RV FAC obtained in?

Answer 60

MOD AP4 or AP4 view

Question 61

What information does RV FAC provide to us?

Answer 61

Provides an estimate of global RV systolic function (RV EF adjacent)

Question 62

In which part of the cardiac cycle is RV FAC done in?

Answer 62

Endocardial tracing measured at end diastole + end systole

Question 63

How do we trace the RV FAC?

Answer 63

From TV annulus along the RV free wall to the apex + back to the annulus along the IVS

Question 64

Is RV FAC or TAPSE a better assessment of RV global function?

Answer 64

FAC - provides greater detail (TAPSE only measures RV function in a single dimension)

Question 65

What is the equation for RV FAC?

Answer 65

RV FAC (%) = 100(EDA-ESA)/EDA

Question 66

RV FAC reflects what 2 components of RV contraction?

Answer 66

Both longitudinal + radial components

Question 67

Should we include or exclude the trabeculations in the RV during a RV FAC?

Answer 67

Include them in our measurement (ignore them)

Question 68

What RV FAC % indicates RV systolic dysfunction?

Answer 68

RV FAC < 35%

Question 69

Why is it not possible to volumetrically quantify the RV the same way as the LV?

Answer 69

B/c we do not have a verified second view/plane