Echo - chamber quantification Flashcards
1
Q
What is the general rule for chamber measurements in regards to heart rate and beats?
A
- Perform on more than one cycle (inter-beat variability)
- Sinus rhythm - average 3 beats
- Atrial fibrillation - average 5 beats
2
Q
What Echo modes can be utilized in linear measurements?
A
- 2D
- M-mode
3
Q
What Echo mode can be utilized to obtain volumetric measurements?
A
- 2D
- 3D
4
Q
Where should the LV end-diastolic dimension be measured?
A
- perpendicular to the LV long axis
- at or immediately below the mitral valve leaflet tips
- 2D >> M-mode (will OVERESTIMATE)
- will avoid oblique measurements
- use guided M-mode if needed
5
Q
What are the advantages of linear measurements in M-mode?
A
- reproducible
- high temporal resolution
- published data
6
Q
What is the preferred method of LV volume measurement?
A
- 2D Biplane Disc Summation (modified Simpsons)
- sum of πr2h
7
Q
How do you perform the 2D Biplane Disc Summation (modified Simpsons) method of LV volume measurement?
A
- trace the blood-compacted tissue interface in 2 and 4 chamber apical views
- straight line at mitral valve level (connect opposite sections of mitral ring)
8
Q
What are methods for calculation of LV systolic function?
A
- Volumetric LVEF
- (LVEDV-LVESV)/LVEDV x 100
- Biplane method of discs (modified Simpson’s) ***currently recommended
- 3D can be used when available/feasible
9
Q
What is a severely abnormal LVEDD (cm)?
- males
- females
A
- > 6.8 cm
- > 6.1 cm
10
Q
Define End-Diastole in the Echo Cardiac Cycle
A
-frame after MV closure
or
-frame with largest LV dimension/volume
11
Q
Define End-systole in the Echo Cardiac Cycle
A
-frame after AV closure
or
-frame with smallest LV dimension/volume
12
Q
What is the standard IVSd (cm) for men and women?
A
men: < 1.0cm
women: < 0.9cm
13
Q
What is the standard PWT (cm) for men/women?
A
- men: < 1.0 cm
- women: < 0.9cm
14
Q
What is IVSd?
A
interventricular septal end-diastolic dimension
15
Q
what is PWT?
A
posterior wall thickness
16
Q
What is LVIDd?
A
left ventricular internal diameter end-diastolic dimension
17
Q
what is LVIDs?
A
left ventricular internal diameter end-systolic dimension
18
Q
What is the standard measurement for LVIDd?
A
- men: < 5.8cm
- women: < 5.2cm
19
Q
What is the standard measurement for LVIDs?
A
- men: < 4.0cm
- women: < 3.5cm
20
Q
What is normal LVEF?
A
- men: > 52%
- women: > 54%
21
Q
What is normal LVEDd in males?
Severely abnormal?
A
- 4.2-5.8 cm
- > 6.8 cm
22
Q
What is the (males) normal LV diastolic volume index (mL/m2)?
Normal LV systolic volume index (mL/m2)?
Severely abnormal LV diastolic volume index (mL/m2)?
A
- < 74 mL/m2
- < 31 mL/m2
- > 100 mL/m2
23
Q
What is normal LVEDd in females?
Severely abnormal?
A
- 3.8-5.2 cm
- > 6.1 cm
24
Q
What is the (females) normal LV diastolic volume index (mL/m2)?
Normal LV systolic volume index (mL/m2)?
Severely abnormal LV diastolic volume index (mL/m2)?
A
- < 61 mL/m2
- < 24 mL/m2
- > 80 mL/m2
25
How to calculate indexed measurements?
Indexed measurements = measurement / BSA
26
56 year old female has LV mass of 98 g/m2 and relative wall thickness of 0.38. What is her LV chamber geometry?
Eccentric hypertrophy
27
Describe method for determining LV mass/LV mass index/Relative wall thickness
29
What is the formula for RWT?
RWT = 2 x PWT / LVEDD
30
What is the linear method (cube formula) for determining LV mass?
LV mass = 0.8 x 1.04 [(IVS + LVIDD + PWT)3 - LVIDD3] + 0.6g
* LV mass = (LV volume epicardium - LV volume endocardium) \* 1.04
\*\*1.04 = specific gravity of myocardium
31
What adverse cardiovascular outcomes are associated with increased left atrial size?
Increased incidence of:
* Atrial fibrillation
* Stroke
* post-MI mortality
* death and hospitalization in patients with dilated cardiomyopathy
32
What is alternative method of calculating the LV mass?
* Linear Method
* Cube formula
* 2D Based formula
* Truncated Ellipsoid
* Area-length
* 3D method
* direct measurement (without geometric assumptions)
33
What is the relationship between pulmonary arterial hypertension and left atrial size?
PAH is not associated with increased left atrial size
34
What is the Law of LaPlace?
* describes the factors that determine left ventricular wall stress, which is a major determinant in myocardial oxygen demand
* LV wall stress is the force acting against the myocardial cells
* LV wall stress is directly proportional to LV pressure and radius
35
What is LaPlace's law (equation) for LV wall stress?
LV wall stress = (LV pressure x LV radius) / 2 x LV wall thickness
36
Describe the changes to LaPlaces law with pressure overload states?
* Concentric hypertrophy (HTN, AS)
* Sarcomeres added in parallel
* Normal or small LV cavity size with thick walls
* Increased:
* LV pressure
* LV wall thickness
* LV mass
* RWT
LV wall stress = ( **Î LV pressure** x LV radius) / 2 x **Î LV wall thickness**
37
Describe the changes to LaPlaces law with volume overload states?
* Eccentric hypertrophy
* Increased diastolic chamber size
* No change in RWT
* Sarcomeres added in series
* Increased:
* LV radius (volume)
* LV wall thickness
* LV mass
LV wall stress = ( LV pressure x Î LV radius) / 2 x Î LV wall thickness
38
What is a normal LV global longitudinal strain?
~ - 20%
39
Explain how to estimate RA pressure using IVC measurements?
* IVC diameter \< 2.1 cm + collapse \> 50% (with sniff) --\> RA pressure = 3 mmHg (normal
* IVC diameter \> 2.1 cm + collapse \< 50% ( with sniff) --\> RA pressure = 15 mmHg
* RA pressure = 8 mmHg --\> IVC parameters don't fit this schema
40
What are two situations in which estimation of RA pressures are unable to be assessed?
* Ventilators
* Young healthy athletes
\*\*
41
What are the six quantitative parameters to evaluate RV systolic function (and abnormal values)?
* TAPSE ( \< 17 mm)
* Tricuspid annular velocity (\< 9.5 cm/s)
* RV 2D fractional area change ( \< 35%)
* RV index of myocardial performance ( \> 0.43 for pulsed Doppler and \> 0.54 for tissue doppler)
* 3D RV EF ( \< 45%)
* RV free wall strain ( \> - 20%)
42
What two RV quantitative parameters are associated with poor prognosis in patients with CHF and PH?
* TAPSE
* Abnormal RV free wall strain
43
What is not a cause of left atrial enlargement ?
**ASD**
* LAE reflects increased wall tension as a result of chronically increased LAP
* ASD commonly cause volume overload of the RA \> LA
44
What are adverse outcomes associated with LAE?
* Increase incidence of A-fib and Stroke
* Increase the risk of overall mortality post-MI
* Increase the risk of death and hospitalization in patients with dilated cardiomyopathy
45
Describe LA size assessment in Echo
* measurements should be obtained at **end-systole**
* **Dedicated LA images**
* ****Avoids foreshortening the LA
* **Maximize left atrial length**
* **Anteroposterior measurement** obtained from PLA window (highly reproducible), frequently underestimates the LA size
46
What should be included/excluded when tracing the left atrial border?
* Included:
* **AV interface should be represented by the mitral annulus plane, not the tipe of the mitral leaflets**
* Excluded:
* Pulmonary vein confluences
* LA appendage
47
What is the relationship between LA volume (on 2D Echo) and CT/MR volumes?
**LA volume is underestimated on 2D Echo when compared to CT/MR**
48
What is the difference between LA volumes obtained in A4C and A2C views?
A4C views typically 1-2 mL/m2 smaller than A2C views
49
What method is not recommended for calculation of LA volume?
**Ellipsoid model using three linear measurements**
* relative inaccuracy of these linear measurements limits this method
50
What are reccommended methods for measuring LA volume?
* **Disc summation method (Biplane method of discs) from a single or biplane imaging (assuming oval shape)**
* ASE recommended
* Area-Length Method
* Biplane method using left atrial areas and lengths from the A4C and A2C views
* 3D method
51
What is one limitation of 3D Echo in assessment of LA volume?
**Lack of standardized methodology**
* 3D \>\> 2D Echo in assessing LA volume --\> correlates better with CT/MR volumes
52
How does RA volume measurement differ from LA volume measurement?
**Right atrial volumes can be calculated from biplane views**
* RA volume is derived from A4C view using the area-length or disc summation methods
* RA volume smaller than LA volume
* RA volumes differ between males and females
53
What is the recommendation for reporting RA size?
**A4C view**
**Indexed for BSA**
**Differentiated by gender**
54
What is the normal RA volume?
**Males 25 +/- 7 mL/m2**
**Females 20 +/- 6 mL/m2**
55
Why are 2D Echo derived aortic diameter measurements preferable to M-mode measurements?
Cardiac motion may result in changes in the position of the M-mode cursor relative to the maximum diameter of the sinuses of Valsalva
56
When evaluating the aortic annular diameter, what view should be utilized?
**PLAX view**
* **which is not the same plane containing the long axis of the LV**
57
The aortic annular diameter is typically measured between these cusps?
**Noncoronary and Right coronary cusps**
58
When should the aortic annulus be measured in the cardiac cycle?
When should other aortic root dimensions (sinus of Valsalva, ST junction, ascending aorta) be measured?
* **mid-systole**
* aortic annulus is largest at this point
* end-diastole
59
Describe IVC relationship to young athletes
* **Dilation of the IVC in athletes is not an indication of elevated RAP**
* studies have shown that trained athletes can have dilated IVC with normal collapisbility
60
When do IVC diameters have the best correlation with RAP?
measured at **end-expiration and end-diastole** using **M-mode Echocardiography**
61
RV dimension and function cutoff values are provided that do not account for gender or body-surface area. In which of the following clinical circumstances would it be appropriate to apply these refernce ranges?
**Ventilated patients**
* Patients that should not be indexed (no specific references):
* Athletes
* Extremes of BSA or height
* Congenital heart disease
62
What is the optimal view for RV measurements?
focused A4C view
* standard A4C is slightly adjusted to center the right heart on the screen and to ensure there is no foreshortening
63
Describe gender differences in RVEF
**RVEF is slightly higher in women than in men**
* Women have smaller chamber volumes
64
Describe the relationship between the RV and LV:
* Stroke volume
* End-diastolic volume
* LVEF
* **Stroke volumes are similar**
* **RVEDV \> LVEDV**
* **RVEF \< LVEF**
65
What is the recommended acquisition rate in 3D Echo assessment of the RV?
**\> 20 volumes per second**
66
What are limitations to acquiring 3D Echo datasets for RVEF?
* Physical or technical:
* **Postoperative state with paradoxical septal motion**
* **TR**
* **Irregular heart rhythm**
* **Load dependency**
* **Poor acoustic windows**
* **Large ventricle (\*\*\*not small ventricles)**
* cannot be captures in 3D volume
67
What is the recommended method for accurate assessment of 3D RVEF?
**Volumetric semiautomated border detection approach**
68
Describe the visual regional wall motion 4 grade classification system
* **Normal** or **Hyperkinetic**
* **Hypokinetic** (reduced thickening)
* **Akinetic** (absent or negligible thickening (e.g. scar)
* **Dyskinetic** (systolic thinning or stretching - e.g. aneurysm)
69
35 year old woman with newly diagnosed PH is about to start treatment. What is her RV size and function based on the images?
**Abnormal RV size and function**
* RV basal dimension 42 mm
* Abnormal \> 41 mm
* TAPSE 15 mm
* Abnormal \< 17 mm
* Systolic annular velocity 8.5 cm/s
* Abnormal \< 9.5 cm/s
70
What is the difficulty with RV dimensions measured in 2D Echo?
**Challenging due to its geometry**
## Footnote
71
When does the ASE recommend indexing RV dimensions for BSA?
**Patients at extremes of BSA**
72
What are conditions in which RIMP can be falsely low?
conditions with elevated RAP --\> shorten IVRT
73
Why is 2D Echo \> M-mode in the assessment of LV linear dimensions?
2D Echo will avoid ablique sections of the ventricle
74
What method of LV volume measurement is inaccurate?
Why?
**Linear measurements**
* assume the LV has a fixed geometric LV shape (such as a prolate ellipsoid), which does not apply in a variety of cardiac pathologies
* For this reason Teicholz and Quinones methods for calculating LV volumes are no longer recommended
75
Describe acquisition of LV volumes:
* 2D or 3D Echo can be used
* 2D should utilize A2C or A4C views
* 3D should utilize a biplane or volumetric measurement
76
What are advantages of using contrast in LV volume assessment?
* **Result in larger volumes**
* better correlation with volumes obtained by CMR
* Improve endocardial definition
* Used when ≥ 2 consectuvie wall segments or \< 80% of myocardium is visualized
77
What is one major limitation of 3D Echo (in LV volume assessment) vs. 2D Echo?
**Limited by poor acoustic windows**
78
What is one major limitation of fractional shortening (in assessment of LV function)?
**Regional wall motion abnormalities (make it inaccurate)**
* CAD or conduction abnormalities make this unreliable
79
What is the current, recommended 2D method for assessing LVEF?
**Biplane method of discs** or **modified Simpson's**
80
What LV segmentation method is used to standardize LV segmentation across cardiac imaging modalities?
**17-segment model**
81
Define aneurysm (based on visual assessment in Echo)
* morphologic entity that demonstrates focal dilatation and thinning (remodeling)
* **akinetic** or **dyskinetic** systolic deformation
* No longer assigned a separate wall motion score (not included in 4 grade scheme)
82
What is one requirement for M-mode and 2D Echo assessments in order to calculate LV mass accurately?
**LV ventricle must be noramlly shaped**
83
What is the process for converting LV volume to LV mass?
What methods of Echo can be utilized?
* **Volume of myocadium x myocardial density (approximately 1.05 g/mL)**
* M-mode, 2D or 3D Echo can be utilized
84
What is the only Echo method that directly measurses myocardial volume
3D Echo
85
What are the upper limits of LV mass?
* Linear measurements
* 2D Echo measurements
* Linear measurements
* 95 g/m2 - women
* 115 g/m2 - men
* 2D Echo measurements
* 88 g/m2 - women
* 102 g/m2 - men
86
Describe the views and myocardial segments
87
Describe blood supply associated with the myocardial segments
88
What are causes of regional wall motion abnormalities in Echo?
* CAD
* Myocarditis
* Sarcoidosis
* Stress-induced (Takotsubo) cardiomyopathy
* Post-operative
* LBBB
* RV epicardial pacing
* RV dysfunction
* caused by volume/pressure overload
89
After implantation of a biventricular pacing device, a 55-year old patient with dilated cardiomyopathy continues to complain of functional class III symptoms and there is no reduction of LV volumes. What factors are important in considering device optimization?
**The iterative technique for AV optimization is based on observation of the LV filling curve at various pacing settings**
* Benefit of AV optimization is supported in landmark CRT studies
90
Describe the iterative technique for AV optimization
* involves PW Doppler mitral inflow estimation with
* shortening and legthening of AV delay and
* observation of the morphology of the transmitral filling wave
91
Describe consequences of optimal and imperfect AV optimization timing and the effects on cardiac filling
* AV delay too short --\> ventricular activation will occur before completion of the mitral A-wave
* AV delay too long --\> ventricular systole will encroach on diastolic filling time
* Optimal setting of paced AV delay --\> VTI of transmitral flow will be optimized, with no truncation of the mitral A-wave
92
What percentage of CRT patients fail to demosntrate a symptomatic or physiologic response to CRT?
**30%**
93
Following anterior myocardial infarction, a 70-year old man has an EF 40% with an end-systolic volume of 95 mL (50mL/m2).
What is his 5-year mortality?
**30% - 5-year mortality**
* ESV \< 95 mL --\> 10% 5-year mortality
94
What is the 95% confidence interval for EF on Echo?
+/- 11%
95
What is the 95% confidence interval for LV mass on Echo?
+/- 60g
96
LV strain has been proposed as a simple quantitative tool for assessing LV function. Which of the following is associated with reduced strain, irrespective of myocardial status?
**Decreased preload**
* reduced preload --\> associated with reduced LV cavity size --\> reduced strain
* reflects the lower position of the ventricle on the Frank-Starling curve
* lower deformation of an already empty LV cavity
97
What is associated with increased LV strain?
* Decreased afterload
* Decreased HR
* Low-dose Dobutamine stress testing
* Higher doses --\> SV falls at higher heart rates
98
What is the most accurate method for LV volume measurement?
**3D Echo with contrast**
99
Given its high workload and distance from nutrient supply, the subendocardium is an important site of pathology. Which techniques could be used to assess subednocardial function?
**Longitudinal, circumferential, and transverse strain**
* Sunbendocardial dysfunction --\> reduction of longitudinal function
* subednocardial fibers have a longitudinal orientation
* Degree of reduction of circumferential and transverse strain is related to the transmural extent of subendocardial dysfunction
100
What are advantages/disadvantages of tissue velocity?
* Advantages
* useful for timing (e.g. synchrony)
* measurement of global phenomena (e.g. e' velocity)
* Disadvantages
* tethering of adjacent segments --\> not a good marker of segmental function
101
What is one new technology that is useful for assessment of myocardial viability?
**Deformation analysis with speckle strain**
* provides information on the transmural distribution of scar
* low-dose Dobutamine has been quantified with both tissue velocity and speckle strain
102
Describe the contributions of Tissue Doppler in regards to:
* Systolic dysfunction
* Viability
* Ischemia
* Diastolic dysfunction
* LV synchrony
* Myocardial characterization
103
Describe the contributions of Strain Rate (TVI and 2D) in regards to:
* Systolic dysfunction
* Viability
* Ischemia
* Diastolic dysfunction
* LV synchrony
* Myocardial characterization
104
Describe the contributions of 3D Volumes in regards to:
* Systolic dysfunction
* Viability
* Ischemia
* Diastolic dysfunction
* LV synchrony
* Myocardial characterization
105
How are new Echo Technologies helfpul in the different stages of heart failure?
* Myocardial deformation (strain)
* 3D Measurements
* Tissue velocity
**All are helpful/useful**
* Tissue velocity
* assessment of tissue e' (myocardial impairement, LV relaxation) and LV filling pressures
* Myocardial strain
* may be a sign of preclinical dysfunction in early-stage disease
* ability to quantify scare may make it helpful in later stages of disease
* 3D
* assessment of volume in latter stages of disease
106
An echocardiogram taken after an acute coronary syndrome shows a mild apical wall motion abnormality with mild LV impairment (EF = 45%) and normal LV volumes. However, global longitudinal strain is decreased (GLS = -13%) while global circumferential strain is preserved. What are the potential explanations for these findings?
**All of the above (DM2, Obesity, hypertensive heart disease, extensive CAD)**
* Strain -12% generally corresponds to LVEF 35%
* strain rate exceeds the visualized minor wall motion abnormality
*
107
What are causes of post-MI systolic murmurs?
**VSD**
**MR (due to papillary muscle rupture/dysfunction)**
108
27 year old man is found to have anterolateral TWI's on ECG for insurance PE.
A2C view with contrast is shown below:
**Apical hypertrophic cardiomyopathy (Yamaguchi variant)**
* Pattern of apical thickening is typical of apical HCM
* Usually benign, although heart failiure may occur because of A-fib and LV aneurysm
109
68 year old woman presents with heart failure. No FH; she has been previously well and takes no medications.
* ECG with low voltage
* Echo / TDI: e' 4 cm/s, pseudonormal filling pattern, LAE
What is the likely diagnosis?
**Amyloidosis**
* CV manifestations of amyloid: CHF, vascular and conduction abnormalities, autonomic dysfunction
* Early stages of disease:
* LV thickening in the absence of h/o HTN or ECG evidence of LVH, and apical sparing is apparrent by strain
* Pseudonormal filling pattern
* Late stages of disease: Restrictive filling pattern, "ground glass" or "speckled" appearance of the myocardium
110
48 year old man with renal impairment has presented late after a myocardial infarction.
* EKG there are no Q waves and there is preservation of R waves.
* Echo there is apical wall motion abnormality
* Coronary angiography: not performed due to concerns for nephrotoxicity
* Myocardial contrast perfusion study is performed with a destruction-replenishment protocol
What is the diagnosis?
**Stunned myocardium in the LAD territory**
* Despite the apical wall motion abnormality --\> bubbles return to this area after the flash --\> indicating intact microcirculation
* Although contrast attenuation in the RCA and CFx segments --\> segments are still thickening
111
What are two uses of myocardial contrast echocardiography?
# define the transmural extent of infarction
and
differentiate stunned from necrotic myocardium
\*\*\*Accuracy in the prediction of functional recovery is comparable to DSE, perfusion scitigraphy, and Cardiac MRI
112
Describe the findings and diagnosis post-MI
* Echo - A (diastole), B (systole)
**RV infarction**
* No change in RV size between diastole and systole consistent with reduced RV function
113
Routine Echo performed 5 days following primary angioplasty to the LAD
Describe the findings
**Apical thrombus**
* Highly mobile apical filling defect, likely representing an early thrombus
* Wall motion abnormality restricted to the apex, without thinning
* Studies have shown presence of LV thrombus in 2% of infarcts, especially with reperfusion time \> 3 hours
114
62 year old patient with DM2 who presented with dyspnea
Describe the findings and diagnosis
**LAD territory scar**
* Reconstructed images equivalent to A4C and A2C views with SAX view at the junction of the mid- and basal segments
* Lower right shows a sequence of nine SAX images from the apex to the base
* LV is enlarged but the wall motion abnormality is restricted to the LAD territor
115
An asymptomatic patient with normal LV function but severe MR has bileaflet prolapse. She is uncertain as to whether to proceed to mitral repair and undergoes an exercise echocardiogram.
**Lack of contractile reserve**
* Resting images are superimposed on post-exercise Images show LV enlargement and LV dysfunction postexercise
* Subclinical LV dysfunction may be identified on the basis of a reduced EF response or LV dilatation with exercise.
116
What situations is mitral valve repair more likely to to fail?
* Anterior leaflet prolapse
* Bileaflet prolapse
117
72 year old woman undergoes Echo because of heart failure symptoms.
Resulting wall motion abnormalities and strain indicated infarctions in which territory?
**Multiple vessels**
* There is thinning of the posterior wall, akinesis of the inferior and basal septal walls, and lateral hypokinesis. Apical function appears reduced in the A4C and A3C views. Combination almost always seen in MVCAD
* Strain: demonstrates low strain in these regions, summarized in the polar map display
118
Describe the findings and diagnosis of the basal-mid and apical walls
**Loss of longitudinal function in the base but not the apex**
* basal-mid posterior curve (yellow) shows lengthening
* apical strain curve (turquoise) shows normal shortening with strain -16% to - 20%
119
What is an important clue that should not be neglected in wall motion analysis?
LV wall thinning
120
63 year old man undergoes an echocardiography prior to stress Echo.
* Biplane Simpson EF is 37% (EDV 172 mL, ESV 108 mL)
* Mean global strain of -14% and segmental waveforms shown
Describe the findings and diagnosis?
**Show extensive late contraction (which may indicate viability)**
* Markers = AVC or aortic valve closure
* Arrows = peak strain following AVC
* This phenomenon of postsystolic contraction can be seen:
* in normal myocardium (but is mild in that setting) or
* as a passive phenomenon (in the setting of dyskinesis)
* but in this case is due to delayed development of shortening, which reflects reduction of myocardial force generation
121
What is a factor that is often neglected in regional wall motion analysis?
**Timing of contraction**
* Would be highly unusual for an ischemic segment to demonstrate synchronous contraction
* Identification of **hypokinesis without delay**, should cause reconsideration about whether the hypokinesis is truly present
122
After and inferior MI, this 68 year old woman developed heart failure, and a new systolic murmur was noted.
Desribe the findings and diagnosis
**Ischemic MR - Posterior Leaflet restriction**
* Posterior leaflet restriction caused by inferoposterior infarction --\>
* anterior leaflet "override" --\>
* posteriorly directed regurgitant jet
123
What causes ischemic MR?
**changes of LV structure and function**
* Posterior leaflet restriction caused by inferoposterior infarction --\>
* anterior leaflet "override" --\>
* posteriorly directed regurgitant jet
124
What are types of MR that occur post-MI?
What are the differences in these types?
* Acute MR
* rupture or stretching of the papillary muscle
* infarct complication related to rupture or stretching of the papillary muscle
* Ischemic MR
* changes of LV structure and function
* inferioposterior infarction --\> posterior leaflet restriction --\> posteriorloy directed regurgitant jet
125
What is the incidence and prognosis related to ischemic MR?
* identified in 50% of post-MI patients, of whom 12% are moderate-severe
* associated with 3-fold increase in heart failure risk and 1.6 fold increased risk of death at 5 years
126
What are the two major mechanisms of ischemic MR?
* displacement of the posterior papillary muscle
* causing anterior leaflet "override"
* posteriorly directed MR
* LV enlargement
* tethering both leaflets
* more central jet
127
What should be considered as a cause in patients with ischemic MR?
Myocardial ischemia and viability (particularly the posterior wall)
as this is an LV process
128
63 year old woman presented after reversing her vehicle into another car at a shopping center. Developed chest pain, dyspnea and EKG with ST-elevations. Echo with strain and deformation tracings are provided, what is the diagnosis?
**Stress cardiomyopathy (Takotsubo)**
* Distribution is atypical for coronary territories - although the wall motion abnormalities invole the apex, they invovle the entire mid-apical LV (which includes right and circumflex coronary territories) but not the base
129
What are additional complications of stress cardiomyopathy?
* LVOT obstruction - SAM
* MR
* Increased LV diastolic pressure (high LV filling pressures)
* Reduced SV
130
Describe the findings and diagnosis
* **LV noncompaction**
* **Diastolic dysfunction (Grade 3) - Restrictive filling pattern**
**\*\*\*\***Color flow doppler demosntrating flow into recesses (typical of noncompaction)
131
What are common complications or abnormalities associated with LV noncompaction?
* Heart failure
* Systemic thromboembolism
* Arrhythmias
