Echo Master Class Flashcards
What does a Bundle Branch Block Cause?
Paradoxical Septal Motion
Protocol for Restriction
- Look for low tissue Doppler
(All e below 5)
| 2. Pulse the Hepatic Vein for reversal
- GLS
What are the bundle Branches?
They are apart of the cardiac conduction system.If blocked they can cause arrythmia.
What is the SA node?
a bundle of nodal tissue located in the upper wall of the right atrium. Serves as the PACEMAKER of the heart. Generates an electrical impulse which depolarized both atria and generates the P wave on the EKG.
What causes paradoxical septal motion?
- Bundle Branch Block
2. Constrictive Pericarditis
What do you do a VTI tracing for?
Mean gradient across a valve(avg)
When do you do a VTI?
1ACROSS ALL VALVE REPLACEMENTS
2. ANY STENOSIS(AoV, MITRAL , TRICUSPID, PULMONIC)
What is the normal mitral valve decel times?
160-240
What is the normal mitral valve area?
4-6 cm2
Normal Mitral E velocity?
.6 - 1.3
Normal Tricuspid inflow( E velocity)?
.3 - .6m/s
Normal pulmonic Flow?
.6 - .9 m/s
Severe Mitral Stenosis?
Greater than 220 m/s
Severe Mitral Valve Area for MS?
Under 1 cm2
Moderate and sever mitral valve area’s for Mitral Stenosis?
Mild - 1.5 - 2.5
Moderate - 1.0 - 1.5
Severe - Under 1 cm
Normal Aov Area?
3.5 - 4
What is the phase called between the E and the A of the mitral valve?
Diastasis
Indications of severe diastolic dysfunction ?
- ABNORMAL TISSUE DOPPLER (FIRST AND FOREMOST )
- Septal TDI below 7
- Decel time below 160
What is the gold standard for coronary artery disease?
Cardiac Cath
Why is a TEE useful in afib patients prior to cardioversion?
Because afib stretches the la which leads to clots in the la/la appendage. You don’t want to cardiovert someone who has a clot because the clot could be expelled out of the la and into the aorta or brain.
What is the most common adult benign tumor?
Myxoma. The number 1 site for a myxoma is in the LA.
What is the most common site for thrombus?
LV apex
What are the indications for a TEE?
- Rule out/source of embolism(soe) ,tumor,mass,myxoma,thrombus
- Rule out evaluate a septal defect
- Rule out infective endocarditis - usually affects areas of turbulent flow
How do you measure the PHT of a valve?
Measure the E slope in CW
What do you look for in Tamponade?
- HEMODYNAMIC COMPROMISE!!!
- Is the IVC plethoric?
- The “M” of the RV in the subs - DIASTOLIC COLLAPSE
What do you take to increase the strength of contraction?
Digitalis
What do you take to decrease the energy needed by the heart?
Beta Blockers
What is mild and severe MR in regurgitant volume?
Mild - Less than 30
Severe - Greater than 60
What is the protocol for Mitral Regurgitation?
You have to get regurgitant volume
- Run CW through mitral valve
- VTI the MR to get a mean and peak
- Drop color down to 20 and get good image
- Click Valves - MR PISA - then get radius(pisa,) , diameter(vena contracta, and enter in the aliasing velocity(bottom number of the color scale.
What is ischemic CMP and what do you look for?
MI. Cardiomyopathy that results from coronary artery disease and heart attack. You look for WALL MOTION ABNORMALITY because due to the MI, a wall should be out.
Where are vegitations located?
Vegitations are located on the low pressure side of the valve
What looks like a veg, but is located on the high pressure side of the valve?
Papillary Fibroelastoma
When you get a high PV velocity ( what do you do)
Pulse before and after the valve
What do you need in order to obtain Mitral
valve area?
Pressure half time
PHT/220
What do you see in a bicuspid aortic valve?
AI and eccentric closure due to asymmetric size of cusp.
What % of patients with coarcts have bicuspid AoV?
50%
What are the layers of the pericardium?
Fiberous Pericardium -Outer
Serous Pericardium
parietal layer
Visceral layer (also called epicardium)
What is the opening of the coronary sinus called?
Thesbian Valve
What is the muscular ridge running anterior from the SVC to the IVC?
Crista Terminalis
Web shaped membrane found in the RA
Chiari network
Muscular projections in the atria and where in the atria are they most common?
Pectinate muscles and they are most common in the appendage
The flap of the foramen ovale is located where?
LA side of the septum
What attaches the valve leaflets to the paps?
Chordae Tendinae
What are the layers of IAS from valve to base?
Primum - at the level of the A-V valves
Secundum - at the level of the foramen ovale
Primum secundum- entrance of the SVC into the RA
Which PA branch is longer and larger? The left or right>
The right PA branch
Perfusion?
Discharge of fluid through a vessel
Name 3 things that would cause the aortic root to expand or dilate?
- Hypertension
- Marfans - connective tissue disorder
- Aortic root aneurysm
- Aortic dissection
In severe AI, what kind of murmur do you hear?
Austin Flint
What do you see on M mode with severe AI?
Early closure of the Anterior mitral valve - increased LVEDP - B Bump - Austin Flint
Premature opening of AoV - Increased LVEDP
Depressed or absent E on mitral
what is the most common TEE finding in stroke patients?
spontaneous echo contrast
Evaluation of the aorta by TEE is comparable to what?
MRI and CT
TEE is a rapid and reliable toool for what?
Aortic disection
TEE can assist in positioning of what?
Intravascular devices
The rate of complication for TEE is what?
Less than 1%
Complications of TEE are worse in patients with?
- h/o esophageal disease
- impaired respitory status
- sleep apnea
What do you do when you see a decel time below 160 and a e/a ratio greater than 1.5?
You valsalva to get the proper severe rating( I or II)
What is Moderate Diastolic Dysfunction?
Normal e/a(greater than 1) on inflow but abnormal tissue.
You valsalve to match the abnormal tissue. If they match, its moderate.
What does Beta Blockers do?
Lowers Blood Pressure. Its any medicine that prevents the response to certain nerve impulses.
What is severe Mitral Stenosis?
Greater than 10 mmhg
What is moderate Mitral Stenosis?
5 - 10 mmhg
What is mild Mitral Stenosis?
Under 5 mmhg
What is multiple myloma and how do you treat it?
Abnormal plasma cells that accumulate in bone marrow where they interfere with the production of normal blood cells.
Catheter ablation?
Procedure used to terminate abnormal tissue in the heart
If the IVC is either
a. dilated -or-
b.doesnt collapse
What do you add?
8
Williams syndrome and Turner Syndrome are associated with what abnormality?
Bicuspid AoV
Regurgitation or insufficiency causes what in the proximal chamber?
Dilation
Where would you find Bisferiens or Corrigans pulse?
In AI
What is called when the RV apex is completley blown out?
Mconnels syndrome
What causes Mconnels Syndrome?
Pulmonary Embolism
Is AoV flutter in systole normal or abnormal?
normal
What do you see in AI on M-Mode?
- AMVL Fluttering
- increases E-Point septal seperation due to increased LVEDP
- Diastolic flutter of the AoV
What do you look for in a patient with HOCM?
SAM!!!
ASH!!
What happens to the Aortic valve during severe Aortic Insufficiency?
Pre-mature opening of the AoV due to increased LVEDP
Mild and severe for vena contracta with AI?
less than .3 is mild
greater than .6 is severe
Total Stroke volume = ?
Forward SV + Regurgitant SV
Stroke Volume = ?
Cross sectional area x VTI
What is mild , moderate , and severe for Dimensionless Index?
mild - greater than .5
moderate - .25 - .5
Severe - less than .25
What is the Dimensionless Index?
VTI of LVOT / VTI AOV
What is mild , moderate, and severe Aortic Valve Area?
Severe - less than 1
Moderate - 1 - 1.5
Severe - greater than 1.5
What is AS MEAN PRESSURE GRADIENT SEVERITIES? HINT DOUBLE SEVERE MS STARTSS THE MILD
MILD - LESS THAN 20
MODERATE - 20 - 40MMHG
SEVERE - GREATER THAN 40 MMHG
What is AoV Peak Pressure Gradient Severities?
greater than 40 - severe
36-40 moderate
16- 36 mild
What are the AoV Peak Velocity to Peak Gradient #’s?(4V squared simplified)?
Velocity Mean 1 = 4 2 = 16 3 = 36 4 = 64 5 = 100
What is the relationship between AoV and Mitral Valve areas?
Direct Recipricol:
Mild - less than 1
Moderate - 1 - 1.5
Severe - greater than 1.5
When do you measure LVOT measurement?
Mid Systole
Pneumothorax ?
Air in thoracic cavity
Why would you give someone atropine?
To speed up a slow heart rate
Pleural effusion?
Fluid in the plural cavity/ opposite of pneumo thorax
Pulmonary edema
Fluid in the lungs
What is IHSS and how does it develop?
Idiopathic Hypertrophic Subaortic Stenosis. It is idiopathic and is more congenital
What causes HOCM?
High blood pressure
What is atropine?
Given to speed up a slow or bradycardic heart rhythm.
What is oximetry?
oxygen content or saturation
What is the normal RV and PA pressures?
PA: systolic - 15 - 30 diastolic 6-12 RV/RA: Systolic 15 -30 Diastolic/RA 6-12
What is the normal LV AO pressure?
AO:
systolic - 100 - 140
diastolic - 60-80
LV /LA
Systolic - 100 - 140
Diastolic 2- 12 LA 6 - 12
What is the normal atria pressures?
RA - 0-6
LA 6 - 12
What kind of catheter is advanced into the ostia of the coronary artery?
Pig tail
Once the catheter is engaged, what kind of contrast is injected into the artery?
iodine based
Once a stenosis is found in the coronary arteries, how is the affected area treated?
The affected area can be treated with angioplasty and/or stenting
What is an angioplasty?
A balloon that is inserted to expand a narrow artery.
What is Left Ventriculography?
Used to define anatomy and function of the LV.
Contrast is injected into the LV cavity.
What kind of information does left ventriculography provide?
global and segmental lv function
mitral regurge
ventricular septal defect
hypertrophic cardiomyopathy
What does Hemodynamic Recordings provide?
It provides information on cardiac pressure throughout the cardiac cycle.
During cardiac cath, pressure tipped transducers are placed i each chamber and the great vessels.
The pressure in each chamber is plotted over time on a strip chart recorder and a pressure tracing is produced
During Left Heart Cath, is the catheter able to reach the LA?
no, because of the sharp turn it would have to make and the damage to the Mitral valve that would occur.
What is an angioplasty?
An angioplasty is performed by means of a catheter with a small balloon attached to it. The catheter is placed within the coronary artery at the level of the plaque and is blown to dilate the artery. An angioplasty is usually followed by stent placement.
What is a atherectomy?
used to oped a partially blocked coronary artery by means of a catheter equipped with a cutting device.
What type of catheter is used in coronary angiography?
pigtail
What is the Peak Instantaneous Gradient?
This is what is calculated using the doppler and the Bernoulli equation. The peak instantaneous pressure gradient is aquired at the same time in the cardiac cycle(Peak Ao vs Peak LV).
Which gradient is used by the cath lab?
Peak to peak
How do you aquire a valve area?
1) Hemodynamic recordings-(during cath, pressure tipped transducers are placed in each chamber and the great vessels to obtain pressures in each chamber. This information is then entered into the Gorlin equation can be used to obtain a valve area.
2) Continuity equation
What is the Cardiac Output?
The volume of blood ejected per minute
What is the normal Cardiac output?
4 to 8 L/min
Why would a patient be put on dialysis?
Whenever they suffered from kidney damage. When the body’s toxin levels become so high that the body is no longer able to filter out by itself; usually after kidney replacement.
What is the ideal frame rate for strain imaging?
50mhz
How many weeks does it take for the heart to fully form?
6 weeks
How long does it take for the heart to take its first beat?
22 days
What is the caudal end of the endocardial tube called? And which tract is it (inflow or outflow)?
vittelo-umbilical vein (inflow tract)
What is the outflow tract of the endocardial tube called?
dorsal aorta
What forms the rt ventricle and the (R) and (L) outflow tracts?
bulbus cordis
The Best Voice Always Attends School
Whaat part of the heart tube forms the Aorta and Pulmonary artery?
Truncus arteriosus
The Best Voice Always Attends School
What forms the Left ventricle?
ventricle canal
The Best Voice ALvays Attends School
Which part of the heart tube forms the AV valve orifices?
atrioventricular canal
The best Voice Alvays attends School
When does cardiac looping occur?
4 weeks
What is the difference between dextro-position and levo-position?
dextro-position - normal looping of the heart( to the right)
levo-position - levo=left - when the tube loops to the left
a congenitally corrected transposition will occur
Which type of bio prosthetic valve transfers from one position to another( self to self)?
Autograft
What type of procedure involves relocation of the pulmonic valve annulus and trunk into the aortic valve position?
Ross procedure
Which type of bioprosthetic valve involves transfers from one human to ANOTHER human? It appears very similar to native valve and may be mounted on stents or stentless.
Homografts
Which type of bioprosthetic valve involves transfers from an animal to a human?
Heterograft
What is the most common ASD?
secundum
Define fenestrated
full of holes
What is anomalous pulmonary venous return?
1 or more pulmonary veins entering SVC/IVC.
Often associated with SINUS VENOSUS ASD
Which ASD is an endocardial cushion defect and would also include an inlet VSD?
Primum ASD
Its the simplest form of atrioventricular defect
Which ASD is commonly associated with trisomy 21 (downs syndrome) and Cleft Mitral Valve?E
Primum ASD
What is the PISA equation?
PISA= regurgitant volume
_______________
Aliasing velocity
PISA= 2 x pie x r squared
Regurg volume = PISA x aliasing velocity
What are the three steps to get EROA to quantify MR?
- Decrease scale
- measure mr PISA
- VTI MR JET AND GET PEAK
- Type in aliasing velocity
What is anomalous pulmonary venous return and what pathology is associated with it?
1 or more pulmonary veins entering the SVC/IVC. It is often associated with SINUS VENOSUS ASD
Why do we leave the pulmonary veins during a transplant?
Because the pulmonary veins will stenose easilly if they are touched
What is it called when PA pressures exceed systemic pressures(LV) and there is a shunt present?
Eisenmiegers
What are you looking for when you see right heart dilation?
ASD
What kind of murmur is heard in an ASD?
fixed split S2
What does an ASD shunt (usually left to right since left sided pressures exceed right side pressure) do to the pulmonary valve?
The ASD increases flow to the right side of the heart, causing the pulmonary valve to close LATER than the aortic valve independent of inspiration or expiration.
What is a PFO?
Patent foramen ovale
Left to right shunt located after 1 year
What is the normal direction of flow in a VSD?
Its Left to Right since Left pressures exceed right pressures.
Is RV volume increased in a VSD?
No, RV volume is not increased because blood is ejected directly OUT of the RVOT.
What does a VSD do to the LA?
Increased blood through the lungs leads to increased blood through the pulmonary veins which causes LEFT ATRIAL ENLARGEMENT.
When does VSD flow mainly occur? During what part of the cycle?
Systole, when the pressure difference between the two ventricles is the greatest.
Increased flow through the lungs can lead to what?
PHTN and symptoms of RV failure: dyspnea orthopnea weight gain cyanosis - eisenmiegers
What effects will a small VSD shunt cause?
usually none. asymptomatic
What type of murmur will a VSD shunt cause?
holosystolic -
remember, VSD are throughout systole.
Its heard best at the LT sternal border
What can a VSD cause?
PHTN
Endocarditis
Aortic regurgitation
What is a direct symptomatic response to Eisemenger Syndrome?
cyanosis
This occurs because in a large ASD, since left sided pressures are greater than left sided pressures, excess flow travels from the left side to the right side; which causes excess flow through the pulmomary arteries. This excess flow throught the pulmonary arteries causes damage to the pulmonary arterioles; causing them to hypertrophy and flow does not easily get through. THIS is what causes back flow or PHTN. As PHTN increases and increases, the Pulmonary Vascular Resistance or right sided pressures also increases(PVR or the “p” in QP/QS). Eventually the right sided pressures will exceed left sided pressures which concludes witH EISENMENGERS SYNDROME.
What is the equation for PISA?
2 x pie x radius squared
or
regurgitant volume
_____________
aliasing velocity
How does a VSD cause endocarditis?
High pressure jet of the VSD flow can damage the endocardial lining and valves allowing vegetations to attach and grow.
How does a VSD cause AI?
High pressure VSD jets that are close to the aortic valve can cause a Venturi affect on the AOV leaflets and they are pulled into the defect causing improper coaptation which leads to AI.
How can you get RVSP without a TR jet with a VSD?
Systemic Blood pressure - (4)(velocity of vsd squared)
How do you get the CSA from a diameter?
.785 x diameter squared
What does a high VSD jet velocity with a normal BP indicate?
low/normal rvsp!! High velocity jets are good!
What is the numerical relationship between the MV mean gradient severity and the VSD size severity?
They are the same:
less than 5 mv/vsd = mild/small
5-10 mv/vsd = moderate
greater than 10 mv/vsd = severe/large
What are 2 ways a VSD can be classified as moderate?
- if its size is between 5 and 10 mm
2. If the size of the VSD is 50 to 100% of the size of the aortic annulus.
What is the most common type of VSD?
Perimembranous - also know as conoventricular or membranous
What is IHSS and how does it develop?
Idiopathic Hypertrophic Subaortic Stenosis. It is idiopathic and is more congenital
What causes HOCM?
High blood pressure
What is atropine?
Given to speed up a slow or bradycardic heart rhythm.
What is oximetry?
oxygen content or saturation
What is the normal RV and PA pressures?
PA: systolic - 15 - 30 diastolic 6-12 RV/RA: Systolic 15 -30 Diastolic/RA 6-12
What is the normal LV AO pressure?
AO:
systolic - 100 - 140
diastolic - 60-80
LV /LA
Systolic - 100 - 140
Diastolic 2- 12 LA 6 - 12
What is the normal atria pressures?
RA - 0-6
LA 6 - 12
What kind of catheter is advanced into the ostia of the coronary artery?
Pig tail
Once the catheter is engaged, what kind of contrast is injected into the artery?
iodine based
Once a stenosis is found in the coronary arteries, how is the affected area treated?
The affected area can be treated with angioplasty and/or stenting
What is an angioplasty?
A balloon that is inserted to expand a narrow artery.
What is Left Ventriculography?
Used to define anatomy and function of the LV.
Contrast is injected into the LV cavity.
What kind of information does left ventriculography provide?
global and segmental lv function
mitral regurge
ventricular septal defect
hypertrophic cardiomyopathy
What does Hemodynamic Recordings provide?
It provides information on cardiac pressure throughout the cardiac cycle.
During cardiac cath, pressure tipped transducers are placed i each chamber and the great vessels.
The pressure in each chamber is plotted over time on a strip chart recorder and a pressure tracing is produced
During Left Heart Cath, is the catheter able to reach the LA?
no, because of the sharp turn it would have to make and the damage to the Mitral valve that would occur.
What is an angioplasty?
An angioplasty is performed by means of a catheter with a small balloon attached to it. The catheter is placed within the coronary artery at the level of the plaque and is blown to dilate the artery. An angioplasty is usually followed by stent placement.
What is a atherectomy?
used to oped a partially blocked coronary artery by means of a catheter equipped with a cutting device.
What type of catheter is used in coronary angiography?
pigtail
What is the Peak Instantaneous Gradient?
This is what is calculated using the doppler and the Bernoulli equation. The peak instantaneous pressure gradient is aquired at the same time in the cardiac cycle(Peak Ao vs Peak LV).
Which gradient is used by the cath lab?
Peak to peak
How do you aquire a valve area?
1) Hemodynamic recordings-(during cath, pressure tipped transducers are placed in each chamber and the great vessels to obtain pressures in each chamber. This information is then entered into the Gorlin equation can be used to obtain a valve area.
2) Continuity equation
What is the Cardiac Output?
The volume of blood ejected per minute
What is the normal Cardiac output?
4 to 8 L/min
Why would a patient be put on dialysis?
Whenever they suffered from kidney damage. When the body’s toxin levels become so high that the body is no longer able to filter out by itself; usually after kidney replacement.
What is the ideal frame rate for strain imaging?
50mhz-80mhz
How many weeks does it take for the heart to fully form?
6 weeks
How long does it take for the heart to take its first beat?
22 days
What is the caudal end of the endocardial tube called? And which tract is it (inflow or outflow)?
vittelo-umbilical vein (inflow tract)
What is the outflow tract of the endocardial tube called?
dorsal aorta
What forms the rt ventricle and the (R) and (L) outflow tracts?
bulbus cordis
The Best Voice Always Attends School
Whaat part of the heart tube forms the Aorta and Pulmonary artery?
Truncus arteriosus
The Best Voice Always Attends School
What forms the Left ventricle?
ventricle canal
The Best Voice ALvays Attends School
Which part of the heart tube forms the AV valve orifices?
atrioventricular canal
The best Voice Alvays attends School
When does cardiac looping occur?
4 weeks
What is the difference between dextro-position and levo-position?
dextro-position - normal looping of the heart( to the right)
levo-position - levo=left - when the tube loops to the left
a congenitally corrected transposition will occur
Which type of bio prosthetic valve transfers from one position to another( self to self)?
Autograft
What type of procedure involves relocation of the pulmonic valve annulus and trunk into the aortic valve position?
Ross procedure
Which type of bioprosthetic valve involves transfers from one human to ANOTHER human? It appears very similar to native valve and may be mounted on stents or stentless.
Homografts
Which type of bioprosthetic valve involves transfers from an animal to a human?
Heterograft
What is the most common ASD?
secundum
Define fenestrated
full of holes
What is anomalous pulmonary venous return?
1 or more pulmonary veins entering SVC/IVC.
Often associated with SINUS VENOSUS ASD
Which ASD is an endocardial cushion defect and would also include an inlet VSD?
Primum ASD
Its the simplest form of atrioventricular defect
Which ASD is commonly associated with trisomy 21 (downs syndrome) and Cleft Mitral Valve?E
Primum ASD
What is acyanotic CHD? When do you normally see it?
defects that do not cause blood oxygen saturation to be decreased.Consist mainly of left to right shunts.
What are some forms of acyanotic defects?
ASD VSD AS PS COARCTATION OF THE AORTA ATRIOVENTRICULAR CANAL L TGA
What is a PDA?
A patent ductus arteriousus is a congenital syndrome in which the ductus arteriosus does not close after birth. Before birth, blood from the SVC travels through the RA/RV and into the PA. It then travels through the ductus arteriousus and directly into the aorta. Remember, before birth , blood flow to the lungs is limited or obsolete.
How can a PDA be treated?
can be tied shut by ligation
Where does aortic coarctation take place?
In the area of the aortic isthmus
What does coarctation of the aorta cause?
Coarctation results in increased pressure in the upper extremities and decreased BP in the LOWER extremeties
Also causes increase LV afterload
What are the three types of coarctation?
- preductal - superior to ligimentum arteriosis
- juxaductal - at the level of the ligimentum arteriosus
- post ductal- inferior to ligimentum arteriousus
What do you doppler when you find a coarctation?
- Pulse down descending to find exact location
2. PULSE THE ABDOMINAL AORTA IN SUBS TO LOOK FOR DAMPENED WAVEFORM WITH DIASTOLIC FLOW.
What is L TGA and what occurs?
L TGA stands for Levo Transposition of the Great Arteries. It occurs when the great arteries and the left and right ventricle are transposed. Basic terms, the ventricles are switched.
Right Atrium -> left ventricle -> pulm artery
Left atrium -> anatomic right ventricle -> aorta
What is Cyanotic heart disease?
Cyanotic heart disease occurs when there is mixing of pure oxygen rich blood with venous blood. In Cyanotic defects, a shunt bypasses the lungs and delivers venous(deoxygenated) blood from the right side of the heart to arterial circulation.
What is the most common Cyanotic heart defect, and the most common cause of blue baby syndrome?
Tetralogy of Fallot
What are the four features of Tetrology of Fallot?
- Ventricular septal defect
- Pulmonary stenosis
- Overriding aorta
- Right Ventricular Hypertrophy
What is the region called in the pulmonary artery just before the pulmonic valve?
infundibulum
if stenosis occurs before the valve, it is then called infundibular stenosis
What does no exagerated A dip on the pulmonary valve mean? (straight line and then closure)
pulmonary stenosis
What is Noonan’s syndrome?
A congenital syndrome in which 50% of patients have valvular pulmonic stenosis.
What are symptoms of pulmonary stenosis?
cyanosis
rv hypertrophy
decreased oxygenation of the blood
dyspnea on exertion
What is the normal O2 sat for right side?
75%
What is a web like structure within the right atrium and is usually seen on echo as a mobile thin membrane in close proximity to the entrance of the IVC?
Chiari network
What is the normal tricuspid valve velocity?
.3 to .7
What is the normal Left Atrium size?
1.9 - 4.0
What is the normal left side O2 sat?
98%
What is the normal mitral valve orifice?
4-6 cm sq.
What is the normal mitral valve velocity?
.6-1.3
The Left ventricular pressure is greater than the right ventricular pressure by approx. _______ times.
5x
Where do the coronary arteries originate?
Sinus of valsalvA
What is the other name for the brachiocephalic artery?
In nominate artery
What is the area between the left subclavian artery and the ligament in arteriosum and what is it prone to?
Aortic isthmus and this area is prone to aortic dissectionso
What causes the second heart sound?
Closure of the semilunar valves
What is it called when the left atrial and left ventricular pressures become even?
Diastasis
What accounts for the third heart sound(in abnormal hearts and may be heard in some children?
Rapid early filling or the “E”
The E or early filling accounts for 75% of ventricular filling.
On ECG, what does the P wave represent?
“A” or atrial kick
What is the normal cardiac output?
4-8 liters/ min
What is the formula for stroke volume?
End diastolic - end systolic
What is the formula for CO?
Stroke Volume x Heart Rate
Inspiration does what to venous return, stroke volume, and cardiac output?
Inspiration increases venous return through a process known as the respiratory pump:
IVC compression decreases venous return because IVC is compressed
Diaphragm movement
During inspiration, the diaphragm moves down, which expands the thoracic cavity and decreases intrathoracic pressure.
Pressure gradient
The negative intrathoracic pressure and positive abdominal pressure create a pressure gradient that pulls blood toward the right atrium.
Right heart function
The right heart temporarily stores the increased venous blood during inspiration and releases it during expiration
Expiration AND standing does what to venous return, stroke volume, and cardiac output?
Decreases venous return, stroke volume, and cardiac output
What are some ways you would eccentuate mitral valve prolapse?
Changes in position or
ValsalvA maneuver
What kind of sound does an left atrium myxoma make?
Loud S1
When does the first heart sound occur?
At the onset of ventricular systole. Mitral closure is normally heard first. These sounds may be labeled M1 and T1
Which valve closures are heard first, the ones on the left( mitral/aov) or the right sided valves(pv/tv)?
Left side
Mitral is heard slightly before tricuspid
Aortic is heard slightly before pulmonic
What exactly causes the S3 sound?
At the beginning of diastole, the rush of blood into the left ventricle causes vibration of the valve leaflets and chordate tendinae
What kind of pathologic states would you hear the S3 sound ?
Heard in certain pathologic states that cause increased left atrial pressure like non compliant LV resulting from conditions such as hypertension,aortic stenosis, ischemic or hypertrophic CMP.
What kind of sounds are heard between S1 and S2?
Ejection sounds. In a stenotic valve, an ejection click may be heard corresponding to the opening of the aortic or pulmonic valve
What kind of sounds are heard when the AV valves open?
Opening snaps. Opening snaps are heard in in stenosis corresponding to the opening of mitral or tricuspid valve.
When would you hear a crescendo-se crescendo sound?
Mitral/Aortic stenosis
When would you hear an opening snap or rumbling?
Mitral stenosis/ tricuspid stenosis
What pathology would you think you would have if you had a severe, sharp pain located precordially that may radiate into the shoulders or neck? Or changing positions and taking deep breaths increases the pain?
Pericarditis
If all other factors remain constant, you would expect a reduction in vessel diameter to increase or decrease velocity ?
Decrease
The incisura on the aortic pressure wave is inscribed when ?
Just after the aortic valve closure
Can a PDA cause left atrial enlargement?
Yes
Anterior movement of the posterior leaflet and a reduced E-F slope are criterion that describe what pathology?
Mitral stenosis
Early closure of the aortic valve in systole is a sign of what pathology?
Mitral regurgitation
The max instantaneous pressure difference between the left ventricle and the left atrium is determined by what pathology?
Mitral regurgitation
What does large color packet size do to accuracy and sensitivity to low flow velocities?
Greater accuracy and greater sensitivity
What is the Fick method?
Measures O2 consumption/ the difference in O2 content between arterial and pulmonary system
What is the normal number of big boxes for normal sinus rhythm?
3-5 big boxes. 60-100 BPM’s
p wave preceding each QRS
Brady= more than 5 bigs(less than 60bpms)
Tachy= less than 3 greater than 100 BPM’s
What is one distinct characteristic of afib on an EKG?
NO DISCRETE P WAVE TO SIGNAL FOR ATRIAL KICK. THATS WHY THERE IS NO “A” ON DOPPLER
What is a characteristic of Aflutter on EKG?
Sawtooth pattern. Rapid discharge of an ectopic focus for atrial depolarization.
What is the difference on 2D between a pacer wire and a catheter?
Pacer wire goes to the RV apex.
Central lines usually stay in the RA
What is Uhl’s anomaly?
Congenital absent RV myocardium also called “parchment heart”
What is phase 4 in the action potential phases?
Resting membrane potential. This is associated with diastole
What is phase 0?
Depolarization of the cell
Sodium
What is phase 1 in the action potential?
Abrupt end to depolarization. Causes a brief period of repolarization. Phase 0-1 represent the R and S waves of the EKG.Closure of sodium
What is phase 2 in action potential?
Represents ST segment on EKG.
Calcium
What is phase 3 on action potential?
Repolarization(slope down) or relaxation. Represents the T wave on EKG.
One small box on EKG = sec?
.04
5 small boxes = 1 large box = ?sec
.20
Five large boxes = ?sec
1
What is the equation to determine heart rate using the number of large boxes on EKG?
300/number of large boxes
What is the typical value for mean left atrial pressure?
10mmhg
What is the typical value for right atrial pressure?
5mmhg
What is typical value for normal hematocrit?
40%
What are the 3 echo Doppler findings in patients with Marfans syndrome?
- dilated aortic root
- Mitral valve prolapse
- Aortic insufficiency
In mitral stenosis, does the posterior leaflet move with the anterior leaflet?
Yea. 80-90% of the time
Which view is best for detecting sub valvular aortic stenosis?
Apical 5 chamber
What is Noonan’s syndrome?
Cardiofacial syndrome with pulmonary stenosis
Increased A dip is indicative of what regarding the pulmonary valve?
Pulmonary stenosis
What is a parachute valve?
Can cause more mitral stenosis than regurgitation
All chord to one papillary muscle
A “parachute mitral valve” on an echo refers to a congenital heart defect where all the chordae tendinae of the mitral valve attach to a single papillary muscle, creating a characteristic “parachute-like” appearance on the echocardiogram, typically identified by a single, centrally located papillary muscle in the left ventricle, best visualized in specific views like the parasternal short axis; this can lead to significant mitral valve stenosis and is often diagnosed with a transthoracic or transesophageal echocardiogram (echo
What is Lutenbachers syndrome?
Mitral stenosis w/ ASD
What is the equation to figure mitral valve area?
PHT
Which valve opens first, tricuspid or mitral?
Tricuspid
What is a homografts?
Human to human
What is an autograft?
Self to self like the Ross procedure
What are the three types of bio prosthetic valves?
Autograft
Homografts
Heterografts
What does a nuclear med stress test Indicate?
The nuc med stress test is a PERFUSION test to locate events of ischemia by looking at the blood that supplies each wall
What is a MUGA test looking for/ indicate?
The MUGA test is a test that uses radioactive solution to get the best estimation of ejection fraction. Is considered to be the most accurate method for EF determination.
In utero, the fetus’s blood is supplied by what?
The placenta
How long after birth does the ductus arteriosus close?
1-2 days
What is the equation to figure the LVEDP using the aortic regurge gradient?
LVEDP=diastolic blood pressure - end diastolic gradient
What is Ehlers-Danlos syndrome?
It’s another connective tissue disorder like Marfans
What maneuvers can be made to accentuate Mitral Valve Prolapse?
ValsalvA and amyl nitrate
What can cause a pseudo MVP diagnosis?
Pericardial Effusion
Where do endocarditis organisms attach to?
The flow side if the valve or the side the blood hits
What are the two main types of nuclear med test that are performed in cardiology?
- Myocardial perfusion test
2. MUGA -measures the contractile function of the myocardium.
What is a lyepomatous atrial septum?
Thickened atrial septum
Beta blockers can be taken to block the impulse of what pathology?
Beta blockers
At what length of the left atrium will a patient regress back into afib after cardioversion?
5cm
(1)What medication do patients take to assist with atrial fibrillation? (2)What is an alternative prognosis to treat afib if meds do not work?
- beta blockers
2. Cardioversion or maze procedure
What does early closure of the aortic valve usually indicate?
Low cardiac output, usually seen in patients w/ dilated CMP
What is the parameter to check when you suspect restrictive cardiomyopathy?
- Pulmonary veins!! Check for “S” wave reversal and large “D”.
- Also don’t forget to check to see if septal E is below 7.
What is hemodynamic compromise usually a result of?
- tamponade
2. RV infarct
What are the 4 main branches of the LCA AND RCA?
LCA:
- LAD- supplies septal,anterior,and apical wall.
- Left Circumflex- supplies atria and posterior left ventricle.
RCA:
- PDA- posterior descending artery supplies the inferior or posterior portion of the heart.
- Acute marginal- Supplies the RIGHT VENTRICLE
What is the equation to determine RVSP when there is a VSD?
Systemic blood pressure - 4(Velocity of VSD) squared ---------------------------- RVSP
DO NOT ADD ASSUMED RA PRESSURE!!
What is the most important finding when you see McConnell Sign?
(McConnell’s= regional wma RV, sparing RV apex).
acute pulmonary embolism
What are the 2 major signs of a dissection?
1) Ripping sharp pain in the abdomen/chest.
2) HYPERTENSIVE ( greater than 200mmhg)
What causes Cardiogenic Shock?
Hypoperfusion (low cardiac output) which results in an acute MI. Can be associated with CMPY with hypotension.
What are the severities for. LDL Cholesterol( numbers)??
Desirable: less than 100
Borderline:
130-159
High Risk:
160-189
What are the 3 types of SVT?
Atrial fibrillation
Paroxysmal supraventricular tachycardia (PSVT)
Atrial Flutter & Atrial Tachycardia
Arrhythmogenic Right Ventricular Dysplasia?
Arrhythmogenic right ventricular dysplasia is a rare type of cardiomyopathy that occurs when the muscle tissue in the right ventricle is replaced with fatty or fibrous tissue. This can lead to disruptions in the heart’s electrical signals and causes arrhythmias. Arrhythmogenic right ventricular dysplasia usually affects teens or young adults and can cause sudden cardiac arrest in young athletes.
How do you treat ischemic cardiomyopathy?
Ischemic cardiomyopathy treatment focuses on managing symptoms and treating heart disease. An individualized plan of treatment may include medications, lifestyle changes, devices and/or surgery. Depending on how severe the condition is, ischemic cardiomyopathy treatment can include:
How do you treat pvc’s?
- Beta Blocker
2. Ablation
What are the classification /stages of heart failure??
- Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
- Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
- Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).Comfortable only at rest.
- Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
- No NYHA class listed or unable to determine.
How do you correct hypertrophic cardiomyopathy?
Myectomy
What is Dimensionless Index?
Ratio of the VTI LVOT to VTI Aortic Valve
Less than .25 - severe
Greater than .3 - mild or mod
What causes a LBBB?
Left bundle branch block
Heart attacks (myocardial infarction)
Thickened, stiffened or weakened heart muscle (cardiomyopathy)
A viral or bacterial infection of the heart muscle (myocarditis)
High blood pressure (hypertension)
Define the diagnosis of ALL.
Leukemia
Acute Lymphocytic Leukemia
Tests and procedures used to diagnose acute lymphocytic leukemia include:
Blood tests. Blood tests may reveal too many white blood cells, not enough red blood cells and not enough platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow.
Bone marrow test. During bone marrow aspiration, a needle is used to remove a sample of bone marrow from the hipbone or breastbone. The sample is sent to a lab for testing to look for leukemia cells.
Blood tests. Blood tests may reveal too many white blood cells, not enough red blood cells and not enough platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow.
Bone marrow test. During bone marrow aspiration, a needle is used to remove a sample of bone marrow from the hipbone or breastbone. The sample is sent to a lab for testing to look for leukemia cells.
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Doctors in the lab will classify blood cells into specific types based on their size, shape and other genetic or molecular features. They also look for certain changes in the cancer cells and determine whether the leukemia cells began from the B lymphocytes or T lymphocytes. This information helps your doctor develop a treatment plan.
Imaging tests. Imaging tests such as an X-ray, computerized tomography (CT) scan or ultrasound scan may help determine whether cancer has spread to the brain and spinal cord or other parts of the body.
Spinal fluid test. A lumbar puncture test, also called a spinal tap, may be used to collect a sample of spinal fluid — the fluid that surrounds the brain and spinal cord. The sample is tested to see whether cancer cells have spread to the spinal fluid.
Treatment
In general, treatment for acute lymphocytic leukemia falls into separate phases:
Induction therapy. The purpose of the first phase of treatment is to kill most of the leukemia cells in the blood and bone marrow and to restore normal blood cell production.
Consolidation therapy. Also called post-remission therapy, this phase of treatment is aimed at destroying any remaining leukemia in the body, such as in the brain or spinal cord.
Maintenance therapy. The third phase of treatment prevents leukemia cells from regrowing. The treatments used in this stage are often given at much lower doses over a long period of time, often years.
Preventive treatment to the spinal cord. During each phase of therapy, people with acute lymphocytic leukemia may receive additional treatment to kill leukemia cells located in the central nervous system. In this type of treatment, chemotherapy drugs are often injected directly into the fluid that covers the spinal cord.
Depending on your situation, the phases of treatment for acute lymphocytic leukemia can span two to three years.
Treatments may include:
Chemotherapy. Chemotherapy, which uses drugs to kill cancer cells, is typically used as an induction therapy for children and adults with acute lymphocytic leukemia. Chemotherapy drugs can also be used in the consolidation and maintenance phases.
Targeted therapy. Targeted drugs attack specific abnormalities present in cancer cells that help them grow and thrive.
A certain abnormality called the Philadelphia chromosome is found in some people with acute lymphocytic leukemia. For these people, targeted drugs may be used to attack cells that contain that abnormality. Targeted therapy may be used during or after chemotherapy.
Radiation therapy. Radiation therapy uses high-powered beams, such as X-rays or protons, to kill cancer cells. If the cancer cells have spread to the central nervous system, your doctor may recommend radiation therapy.
Bone marrow transplant. A bone marrow transplant, also known as a stem cell transplant, may be used as consolidation therapy in people at high risk of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia to re-establish healthy bone marrow by replacing leukemic bone marrow with leukemia-free marrow from a healthy person.
A bone marrow transplant begins with high doses of chemotherapy or radiation to destroy any leukemia-producing bone marrow. The marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant).
Clinical trials. Clinical trials are experiments to test new cancer treatments and new ways of using existing treatments. While clinical trials give you or your child a chance to try the latest cancer treatment, treatment benefits and risks may be uncertain. Discuss the benefits and risks of clinical trials with your doctor.
ALL in older adults
Older adults, such as those older than 60, tend to experience more complications from ALL treatments. And older adults generally have a worse prognosis than children who are treated for ALL.
Discuss your options with your doctor. Based on your overall health and your goals and preferences, you may decide to undergo treatment for your ALL.
Some people may choose to forgo treatment for the cancer, instead focusing on treatments that improve their symptoms and help them make the most of the time they have remaining.
Cystic Fibrosis
Cystic fibrosis affects the cells that produce mucus, sweat and digestive juices. These secreted fluids are normally thin and slippery. But in people with cystic fibrosis, a defective gene causes the secretions to become sticky and thick. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the lungs and pancreas.
People with cystic fibrosis have a higher than normal level of salt in their sweat. Parents often can taste the salt when they kiss their children. Most of the other signs and symptoms of cystic fibrosis affect the respiratory system and digestive system. However, adults diagnosed with cystic fibrosis are more likely to have atypical symptoms, such as recurring bouts of inflamed pancreas (pancreatitis), infertility and recurring pneumonia.
Respiratory signs and symptoms
The thick and sticky mucus associated with cystic fibrosis clogs the tubes that carry air in and out of your lungs. This can cause signs and symptoms such as:
A persistent cough that produces thick mucus (sputum) Wheezing Breathlessness Exercise intolerance Repeated lung infections Inflamed nasal passages or a stuffy nose Digestive signs and symptoms
The thick mucus can also block tubes that carry digestive enzymes from your pancreas to your small intestine. Without these digestive enzymes, your intestines aren’t able to completely absorb the nutrients in the food you eat. The result is often:
Foul-smelling, greasy stools
Poor weight gain and growth
Intestinal blockage, particularly in newborns (meconium ileus)
Severe constipation
Frequent straining while passing stool can cause part of the rectum — the end of the large intestine — to protrude outside the anus (rectal prolapse). When this occurs in children, it may be a sign of cystic fibrosis. Parents should consult a physician knowledgeable about cystic fibrosis. Rectal prolapse in children may sometimes require surgery. Rectal prolapse in children with cystic fibrosis is less common than it was in the past, which may be due to earlier testing, diagnosis and treatment of cystic fibrosis.
What is varapamil?
What is verapamil?
Verapamil is a calcium channel blocker. It works by relaxing the muscles of your heart and blood vessels.
Verapamil is used to treat hypertension (high blood pressure), angina (chest pain), and certain heart rhythm disorders.
Verapamil injection is used to rapidly or temporarily restore normal heartbeats in people with certain heart rhythm disorders.
Sick Sinus Syndrome
Tacky/Brady
What is necrosis?
Cellular damage due to lack of oxygen. Occurs in a myocardial infarction and is the determining factor in the difference between infarct and ischemia.
Hypoxia
Diminished availability of oxygen to the body.
Linear
One dimensional
What are the the “-sartans” classified as?? (Losartin, cozaar,valsartan, diovan).
ARB’s. -
Angiotensin II Receptor Blockers
Multiple myeloma?
Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell. Plasma cells help you fight infections by making antibodies that recognize and attack germs.
Multiple myeloma causes cancer cells to accumulate in the bone marrow, where they crowd out healthy blood cells. Rather than produce helpful antibodies, the cancer cells produce abnormal proteins that can cause complications.
Wolf Parkinson’s White Syndrome
Abnormal Congenital cardiac conduction syndrome that results in symptomatic and life threatening arrhythmias.
Watchmans Implant?
A balloon device that is inserted in the Left Atrial Appendage to block blood flow into the LAA. Endothelization occurrs after 3 years.Used for AF patients who can’t take blood thinner.
Predicated
- To base or establish (a statement or action, for example): I predicated my argument on the facts.
Sepsis / septic shock
There are three stages of sepsis: sepsis, severe sepsis, and ultimately septic shock.
Sepsis is a serious medical condition resulting from an infection. As part of the body’s inflammatory response to fight infection, chemicals are released into the bloodstream. These chemicals can cause blood vessels to leak and clot, meaning organs like the kidneys, lung, and heart will not get enough oxygen. The blood clots can also decrease blood flow to the legs and arms leading to gangren
al·tru·is·tic
/ˌaltro͞oˈistik/
showing a disinterested and selfless concern for the well-being of others; unselfish.
“it was an entirely altruistic act”
Turner Syndrome ??
Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects.
A chromosomal disorder in which a female is born with only one X chromosome
Turner syndrome results from a missing or incomplete sex chromosome.
Symptoms include short stature, delayed puberty, infertility, heart defects, and certain learning disabilities.
Treatment involves hormone therapy. Fertility treatment may be necessary for women who want to become pregnant.
From Mayo Clinic and others • Learn m
The risk of congenital heart defects such as bicuspid aortic valves, aortic coarctation, other valve abnormalities, and septal defect is increased. Likewise, the risk of aortic dissection at a young age is increased, as is the risk of hypertension, ischemic heart disease, and stroke.
Sepsis
Global hypo perfusion!
manifest as hypotension, decreased distal perfusion, and organ perfusion
CTO?
Chronic total occlusion (CTO) is a common heart disorder in many patients with coronary artery disease. About 20% to 25% of patients with coronary artery disease will also have a chronically occluded artery.
Impella
The Impella pulls blood from the ventricle and pushes it out into the aorta, delivering oxygen-rich blood to the rest of your body. This allows your heart to rest while the doctor performs the PCI. Once the PCI procedure is complete, the Impella is turned off and guided out
Cardiac output
Volume of blood pumped in 1 min
Stroke Volume
Volume of blood pumped in each beat
Formula for CO
Cardiac output= stroke volume x heart rate
How do you calculate fractional shortening to assess RV function?
End diastolic area - end systolic area
Answer divided by the end diastolic area
What is normal fractional are change for rv?
35%
What is strain?
Strain represents the hearts deformation in response to applied force.
What are the 2 types of Amyloid and which one is more common?
AL - plasma cells in bone marrow
ATTR- Transthyretin amyloid from the liver
Wolf Parkinson White Syndrome
SVT
Congenital heart defect where an extra pathway is created for signals to travel between the hearts upper and lower chambers creating a fast heart beat.
Asytole
FLAT LINE
when your hearts electric system fails entirely causing your heart to stop pumping blood entirely
Restrictive vs non restrictive VSD
Restrictive:
<.5cm
Small L to R shunt
Normal RV output
75% spontaneously close <2yrs
Non-restrictive:
Greater than 1 cm
Equal RV and LV pressures
Large Hemodynamically significant L to R shunt
Rarely close spontaneously
Pulmonary Hypertension Complications??
Atrial fibrillation
Intracardiac thrombus
DVT
Renal and hepatic failure
Carpentier Classification of MR
“At Dawn, people record tigers”
Type 1: MV dysfunction due to mitral annular dilatation. (AD)
Type 2: MV prolapse ,flail due to chordal rupture (Prolapse)
Type 3a: leaflet restriction is systole and diastole (Rheumatic)
Type 3b: Tethering: Dysfunction in systole only due to tethering (Tethering)
What is concurrent with diastolic MR?
AV block
Increased LVEDP (could be due to significant AI)
Persistent Left SVC = Left svc dump into the Left atrium or coronary sinus. Which arm do you do a bubble study in?
Left arm for left SVC
Persistent Left SVC = Left svc dump into the Left atrium or coronary sinus. Which arm do you do a bubble study in?
Left arm for left SVC
What is the difference between ischemia and infarction?
Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is obstructed by a partial or complete blockage of a coronary artery by a buildup of plaques (atherosclerosis).
If ischemia is severe or lasts too long, it can cause a heart attack (myocardial infarction) and can lead to heart tissue death. In most cases, a temporary blood shortage to the heart causes the pain of angina pectoris. But in other cases, there is no pain
If the plaques rupture, you can have a heart attack (myocardial infarction).
What is the difference between ischemia and infarction?
Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is obstructed by a partial or complete blockage of a coronary artery by a buildup of plaques (atherosclerosis).
If ischemia is severe or lasts too long, it can cause a heart attack (myocardial infarction) and can lead to heart tissue death. In most cases, a temporary blood shortage to the heart causes the pain of angina pectoris. But in other cases, there is no pain
If the plaques rupture, you can have a heart attack (myocardial infarction).
What is ischemia?
The term ischemia means that blood flow to a tissue has decreased, which results in hypoxia, or insufficient oxygen in that tissue, whereas infarction goes one step further and means that blood flow has been completely cut off, resulting in necrosis, or cellular death
What is Ischemic Cardiomyopathy
Ischemia over a long period of time.
Ischemic cardiomyopathy (ICM) is a term that refers to the heart’s decreased ability to pump blood properly, due to myocardial damage brought upon by ischemia. When discussing the term ICM, coronary artery disease (CAD) has to be addressed. CAD is a condition characterized by the formation of plaques in the coronary blood vessels, decreasing their capacity to supply nutrients and oxygen to the contractile heart muscle. ICM has a spectrum of clinical changes which eventually leads to congestive heart failure (CHF). Initially, there is a reversible loss of cardiac contractile function because of decreased oxygen supply to the heart muscle; however, when there is ischemia for a prolonged period, there is irreversible cardiac muscle damage resulting in cardiac remodeling. Remodeling is primarily achieved by myocardial fibrosis which results in decreased cardiac function, arrhythmia, and possible cardiac conduction system impairment.
Go to:
Etiology
CAD most commonly causes ischemic cardiomyopathy. Lack of adequate blood supply is not able to meet the myocardial metabolic demands that lead to cell death, fibrosis, left ventricular enlargement and dilation.
Risk factors for ischemic cardiomyopathy can be classified as modifiable and non-modifiable.
Modifiable: Diabetes mellitus, hypertension, tobacco abuse, hyperlipidemia, obesity, and sedentary lifestyle
Non-modifiable: Age, gender, and family predisposition
Go to:
Epidemiology
CAD is the leading cause of death in adults in the United States.
Explain expiratory diastolic reversal in hepatic veins with Constrictive pericarditis
The reduction in left heart filling during inspiration causes a reduction in mitral inflow velocity and a shift of the intraventricular septum towards the LV
WITH EXPIRATION, LEFT HEART FILLING INCREASES WHICH SHIFTS THE INTERVENTRICULAR SEPTUM BACK TO THE RV, LEADING TO REDUCED FILLING TO THE RIGHT SIDE OF THE HEART AND A LATE DIASTOLIC FLOW IN HEPATIC VEINS
Explain Pulsus Paradoxis and when do we see it?
It’s an exaggerated drop in systemic blood pressure during inspiration.
Seen in moderate to severe tamponade tamponade and constrictive pericarditis
If posterior prolapse causes an anterior jet, what is the direction of the jet in a restricted posterior leaflet?
Posterior
Inferior LV infarcts are most associated with what?
RV infarction
What is the main cause of cardiogenic shock?
MI
What is the cause of septic shock?
Bacterial infection
What is hypovolemic shock?
Hypovolemic shock is a dangerous condition in which your heart can’t get your body the blood (and oxygen) it needs to function. This happens because you’ve lost a large amount ― more than 20% ― of your blood volume. You can also get hypovolemic shock from losing a large amount of fluids after a lot of diarrhea, throwing up or sweating.
What is hypoglycemia?
A condition in which the body’s blood sugar level goes below the standard range
What is RV FAC?
FAC = Fractional Area Change
. FAC is calculated as
end-diastolic area-end-systolic area)/end-diastolic area.
In the example shown FAC is 50% (normal value . 35%).
What is RV FAC?
FAC = Fractional Area Change
. FAC is calculated as
end-diastolic area-end-systolic area)/end-diastolic area.
In the example shown FAC is 50% (normal value . 35%).
NSTEMI
Unstable angina is caused by partial rupture of an artery and does not permanently damage the heart muscle.
2.NSTEMI is caused by a block in a minor artery or a partial obstruction in a major artery.
1.STEMI occurs when a ruptured plaque blocks a major artery completely
Palliative Care?
Palliative care can assist you in navigating the pros and cons of medical interventions such as ongoing hospitalizations or procedures related to your serious illness. Palliative care providers can also support you in your decision-making processes, including helping you with advance care planning — thinking, discussing, and recording your health care wishes to ensure they’re known, understood, and respected if and when you become unable to advocate for yourself.
Palliative Care?
Palliative care can assist you in navigating the pros and cons of medical interventions such as ongoing hospitalizations or procedures related to your serious illness. Palliative care providers can also support you in your decision-making processes, including helping you with advance care planning — thinking, discussing, and recording your health care wishes to ensure they’re known, understood, and respected if and when you become unable to advocate for yourself.
What is Lisinopril?
Ace Inhibitor
It can treat high blood pressure and heart failure. It can also reduce the risk of death after a heart attack
Increase CK levels?
Creatine kinase (CK)
The small amount of CK that’s normally in your blood mainly comes from your skeletal muscles (the muscles that are attached to your bones and tendons). Any condition, injury or event that causes muscle damage and/or interferes with muscle energy production or use increases levels of CK in your blood
Increase CK levels?
Creatine kinase (CK)
The small amount of CK that’s normally in your blood mainly comes from your skeletal muscles (the muscles that are attached to your bones and tendons). Any condition, injury or event that causes muscle damage and/or interferes with muscle energy production or use increases levels of CK in your blood
Formula for AI volume?
LVOT SV - MV STROKE VOLUME
Formula for AI volume?
LVOT SV - MV STROKE VOLUME
Formula for Aortic RF??
AI volume / LVOT SV
AI volume = LVOT SV - MV SV
Metabolic Syndrome?
A cluster of conditions that increases the risk of heart disease, stroke and diabetes.
Metabolic syndrome includes high blood pressure, high blood sugar, too much body fat around the waist and irregular cholesterol levels. The risk of metabolic syndrome increases with age. Hispanics also are at increased risk.
Metabolic Syndrome?
A cluster of conditions that increases the risk of heart disease, stroke and diabetes.
Metabolic syndrome includes high blood pressure, high blood sugar, too much body fat around the waist and irregular cholesterol levels. The risk of metabolic syndrome increases with age. Hispanics also are at increased risk.
Most efficient way to treat Afib?
Pulsed field ablation. . This new technology uses short electrical pulses to ablate cells that are triggering the AFib, without damaging surrounding structures. Studies suggest this new, highly precise technique safely and effectively treats atrial fibrillation with faster procedure times than traditional methods and with low complication rates.
What is can be found in the LV apex which is extremely laminar but not a clot?
In hypereosinophilic syndrome (HES—like the gas station!!) eosinophils damage the tissues that they infiltrate. Sort of like infiltrative disease. Common target organs include the skin, lung, and gastrointestinal tract. Less commonly, patients can have potentially life-threatening damage to the cardiovascular system and brain. Activated eosinophils may damage tissues in a number of mechanisms, which are described in more detail separately. (See “Eosinophil biology and causes of eosinophilia”.)
What is retroaortic anomalous coronary (RAC)?
It is visualized in a modified apical four chamber view on transthoracic echocardiography, tilting the imaging plane anteriorly. It is found in near apposition to the atrial side of the atrioventricular groove, appearing as a tubular, hyperechoic structure oriented perpendicularly to the course of the aortic root 2. It may also be viewed from apical two and long axis views, found just superior to the mitral annular plane 3.
Decompensated Heart Failure?
Clinical syndrome in which structural or functional change in the heart leads to its inability to eject blood.
What are image enhancers (Contrast Agents)?? What do they do?
Contrast agents are pharmaceuticals that increase the information content of diagnostic images. They serve to improve the sensitivity and specificity of diagnostic images by altering the intrinsic properties of tissues, which influence the fundamental mechanisms of contrast.
How many methods can be used to obtain Stroke Volume?
3
- 2D Simpsons (EDV-ESV)
- 3D (EDV-ESV)
- Doppler ( CSA LVOT x LVOT VTI)
How do you calculate ERO without PISA?
Reg VOLUMe/ R VTI
Hereditary hemorrhagic telengiectasia(HHT)?
Genetic disorder in which blood vessels do not develop normally leading to bleeding that can be life threatening. We do a bubble study to screen for PAVM in HHT patients.
RAC?
Retroaortic Anomalous Coronary Artery- rare condition where the left coronary artery or circ originates from the right coronary artery artery. RAC appears as a tubular structure that’s highly echogenic and located near the atrioventricular groove.
RAC?
Retroaortic Anomalous Coronary Artery- rare condition where the left coronary artery or circ originates from the right coronary artery artery. RAC appears as a tubular structure that’s highly echogenic and located near the atrioventricular groove.
Functional MR
Functional mitral regurgitation (FMR) is a condition where the mitral valve leaflets don’t close properly due to left ventricular (LV) or atrial remodeling. It can be categorized as either ventricular or atrial, and is often a result of a combination of the two:
Functional MR
Functional mitral regurgitation (FMR or secondary MR- tethering from MI or when valves don’t close which is not due to MV disease)is a condition where the mitral valve leaflets don’t close properly due to left ventricular (LV) or atrial remodeling. It can be categorized as either ventricular or atrial, and is often a result of a combination of the two:
What is the new ablation to treat arrhythmia patients at Yale?
(PFA)Pulsed Field ablation- uses short electrical pulses to treat Afib. PFA is faster and safer than traditional methods, and has low complication rates.
ECMO assisted ablation is another one. This is because ablations can become taxing to the heart and people with weak hearts may not be able to candidate. ECMO assisted (heart-lung machine) ablation allows those patients with weak hearts the opportunity to have an ablation.
Test to diagnose cardiac sarcoidosis ?
PET Scan
Test to diagnose Amyloid?
PYP
Polyphosherate
What is a secondary test for EF?
1.Cardiac MRI (CMR)
2. MUGA
Hypovolemia?
Lack of blood( fluid) , water or lymphatic fluid volume circulating in the body.
Can cause hypovolemic shock
Hypovolemia?
Lack of blood( fluid) , water or lymphatic fluid volume circulating in the body.
Can cause hypovolemic shock
What is regurgitant fraction?
The ratio of the volume of blood that flows backward through a valve to the total volume of blood pumped through the heart. Expressed as a percentage.
What does strain actually measure?
Longitudinal strain is the change in length of a material relative to its original length when a force is applied in the same direction as its original length.
It is the measure of deformation experienced by an object in the direction of the applied force, relative to its original length
DVI or DI formula for prosthetic AV and MV?
AV = LVOT VTI/ PROSTHETIC VTI (CW)
MV= PROSTHETIC VTI(CW) / LVOT VTI
Lymphoma
A cancer of the lymphatic system.
Lymphoma is a cancer of the lymphatic system. The lymphatic system is part of the body’s germ-fighting and disease-fighting immune system. Lymphoma begins when healthy cells in the lymphatic system change and grow out of control.
The lymphatic system includes lymph nodes. They are found throughout the body. Most lymph nodes are in the abdomen, groin, pelvis, chest, underarms and neck.
The lymphatic system also includes the spleen, thymus, tonsils and bone marrow. Lymphoma can affect all these areas and other organs in the body.
There are many types of lymphoma. The main subtypes are:
Hodgkin lymphoma (formerly called Hodgkin disease).
Non-Hodgkin lymphoma.
Types of Amyloid and how do we test for it?
ATTR (Amyloid Transport Protein Transthyretin) Amyloidosis
There are several types of ATTR amyloidosis, including:
1.ATTRw (Senile systemic amyloidosis): Caused by age-related amyloid deposition, this is the most common type of cardiac amyloidosis.
2.ATTRm (Familial amyloidosis): Caused by mutant TTR
Labs: blood and urine to detect abnormal proteins
Biopsy : A biopsy taken from the fat under the abdomen or bone marrow
Imaging: PYP POLYPHOSPERATE NUCLEAR
MRI
ECHO
Types of Amyloid and the gold standard test for it
ATTR (Amyloid Transport Protein Transthyretin) Amyloidosis
There are several types of ATTR amyloidosis, including:
1.ATTRw (Senile systemic amyloidosis): Caused by age-related amyloid deposition, this is the most common type of cardiac amyloidosis.
2.ATTRm (Familial amyloidosis): Caused by mutant TTR
Formula for EF?
SV \ EDV = EF
EDV-ESV / EDV
Formula for EF?
SV \ EDV = EF
EDV-ESV / EDV
PPO and HMO?
PPO- permits an employee to pay a lower rate for health care services if the employee agrees to use health care providers approved by the PPO.(58%)
HMO- Health Maintenance Organization. Restricts employees choice of health care provider to the HMO (13% of American employees)
Difference between RV pressure/volume overload?
Rv volume over load: When the RV diastolic pressures approaches or exceeds LV diastolic pressures, the the IVS shifts only during mid diastole
RV pressure overload- When the RV diastolic and systolic pressure approaches or exceeds LV pressures, the IVS motion reverses over the entire cardiac cycle.
Rheumatic heart disease?
Occurs after an untreated strep infection.
A condition that occurs when the heart valves are damaged by rheumatic fever -which is an autoimmune response to streptococcus infection.
RHD can happen after an untreated strep infection.
Carcinoid Heart Disease? CHD
Valvular fibrosis (thickening) or carcinoid plaque on the right sided heart chambers and valves from vasoactive substances released from tumor. Over time , leaflets become fixed in a semi open position, leading to a combination of stenosis and regurgitation
What is the most common connective tissue disease?
Rheumatoid Arthritis
Pulses Paradoxis?
Abnormal drop in blood pressure when a person inhales
Continuity for Aortic valve area?
Aortic Valve Area = (LVOT Cross-Sectional Area x LVOT VTI) / Aortic Valve VTI
TLC?
Triple Lumen Catheter inserted into the internal jugular vein.
Study objectives: Chest radiographs are required in many institutions by protocol after the insertion of a right internal jugular vein triple-lumen catheter (TLC), even if the anterior approach is used
What is the Bicaval TricValve?
A transcatheter system of 2 self expanding bovine tissue valves mounted on stents meant to be placed in the SVC and IVC. Caval valve implantation reduces venous regurgitation and improve right sided hemodynamics. This promotes reverse RV remodeling and reduces peripheral congestion.
Elevated central venous pressure and systolic flow reversal in the vena cava are primarily responsible for end -organ venous congestion manifesting as ascitis,hepatosplenomegaly and peripheral edema.
What is normal values for LVOT VTI?
20cm
Normal range is:
17-23cm
What is normal values for LVOT VTI?
20cm
Normal range is:
17-23cm
What disease state can result in a tumor thrombus which can be scene in the IVC?
Renal Cell Carcinoma.
What is Chagas’ disease??
Infected forms of Trypanosoma cruzi present in the feces of reduvidae insects penetrate the skin or conjunctiva of people living in poor rural housing in South America. pioneering necropsy work17 pointed out the high rate of LV chagasic apical aneurysm found in these patients. This result was confirmed by others studies,14,18 including a large series of 1078 autopsies19 in which apical aneurysms and pericardial effusions were found in ≥ half of cases,
What is the cut off for RV base?
4.2cm
What agent is used in nuclear stress test to increase HR?
Lexi scan.
Adenosine is another stress agent which is less selective and causes more side effects.
What is Pulses Paradoxis?
Drop in Blood pressure when a person inhales.
What pressure in Right Heart Cath is used to assess RVSP?
In the absence of RV outflow track obstruction or pulmonary stenosis, the PASP (Pulmonary Artery Systolic Pressure) is the same as RVSP.
How do you get the surface area of the hemispheric PISA shell?
2(pie)r2(squared)
What is the formula for EROA
EROA=
2xpie(3.14)xr(squared) = shell surface area
X nyquist limit (30??)
Divided by
V Max(reguritation/stenosis v max)
What medication is the first line of defense to slow down SVT?? It can also be used to slow HR to check for P waves.
Adenosine
What is troponin cutoffs??
The first highly sensitive cardiac troponin assay (Elecsys Troponin T
Gen 5 Short Turnaround Time [STAT] immunoassay by Roche Diagnostics) was approved by the US Food and Drug Administration (FDA) in early
2017. The FDA approval included sex-specific cutoffs of 14 ng/L for women and 22 ng/L for men, or a single cutoff of 19 ng/L, with recommended use in conjunction with other signs and symptoms for the diagnosis of Ml.
What is pseudo severe AS?
This can occur when there’s a low-flow state (e.g., due to reduced left ventricular ejection fraction or other factors) and the transvalvular flow is not high enough to fully open the valve, leading to an overestimation of the stenosis severity.
In pseudo-severe AS, the AVA increases significantly with increasing flow, and the mean gradient may not increase as much as in true-severe AS.
What is ICE?
Intracardiac echocardiography (ICE) is a specialized echocardiography technique that uses a catheter-based ultrasound probe to image the heart from within, providing real-time, high-resolution views of cardiac structures and blood flow, particularly useful for guiding interventional and electrophysiology procedures.
What is PEA?
a cardiac arrest rhythm where the heart shows organized electrical activity on an ECG but there’s no palpable pulse or effective circulation.
What is the myocardial performance index?
The myocardial performance index (MPI), also known as the Tei index, is a non-invasive echocardiographic parameter that assesses the overall function of the heart. It reflects both systolic (contraction) and diastolic (relaxation) function.
MPI is calculated using the following formula:
MPI = (Isovolumetric contraction time + Isovolumetric relaxation time) / Ejection time .
Difference between EOA and EROA?
In echocardiography, EOA (Effective Orifice Area) measures the minimal cross-sectional area of a valve’s downstream jet, while EROA (Effective Regurgitant Orifice Area) measures the area of a regurgitant jet, indicating the severity of a valve leak
The EOA and EROA represent the area of the vena contracta, not valve area or anatomical orifice area(AOA). The EOA is smaller than the the true AOA.
EOA and EROA are both used to assess the severity of valve stenosis and regurgitation respectively.
EOA is used to assess the severity of stenosis, while EROA is used to assess the severity of regurgitation
When or what phase do you measure PISA shell?
To avoid over estimation of EROA, measurement of the PISA radius should be performed at the same time as peak (largest) MR velocity(mid to late systole)
The difference between maximum instantaneous pressure gradient and mean pressures gradient?
Maximum Instantaneous
From the peak velocity, the maximum instantaneous pressure gradient is calculated using the modified Bernoulli equation:
P= 4V(2)
Mean pressure gradient:
The mean pressure gradient can be determined from the average of different peak velocities measured at different intervals from start to finish of the jet.
What does the LAD supply?
-Anterior + Anterior Septum LV Wall
-Entire Apex including RV
/ Could extend as far as mid inferior LV
What does the Left Circ supply?
-Left Atrium
- Inferolateral segments
-Inferior LV wall
-Lateral LV Apex
-and a variable amount of amount of Anterior lateral
Coronary distribution for RCA?
-Right Atrium
-RV Free wall
- Inferior LV (Base and Mid)
- BIS and sometimes MIS
What is the difference between ischemia and infarction?
Myocardial ischemia-
Ischemia is the result of impaired vascular perfusion which deprives the affected tissue of nutrients and oxygen. CAN BE REVERSABLE. Its reversible ability depends on the duration of the ischemic period and the metabolic demands of the tissue.
Myocardial ischemia occurs when there is insufficient blood supply to the myocardium due to decreased or impaired coronary artery perfusion or increased metabolic demands of the myocardium due (severe AS and HCM)
INFARCTION-
Infarction is death or “necrosis of the tissue” which is a result of long standing ischemia or total occlusion.
NOT REVERSIBLE
What is angina pectoris?
Angina pectoris is the major symptom of ischemic heart disease. Angina refers to cardiac chest pain or discomfort resulting from a temporary imbalance between myocardial oxygen supply and demand .
What is the most common cause of CAD?
Atherosclerosis
What is Wolf Parkinson’s White (WPW) syndrome?
Wolff-Parkinson-White (WPW) syndrome is a heart condition present at birth. That means it’s a congenital heart defect. People with WPW syndrome have an extra pathway for signals to travel between the heart’s upper and lower chambers. This causes a fast heartbeat. Changes in the heartbeat can make it harder for the heart to work as it should.
What is regurgitant fraction?
the percentage of blood that flows backward through a heart valve (like the mitral or aortic valve) instead of forward, indicating the severity of valve regurgitation. It’s calculated as the regurgitant volume divided by the total stroke volume, expressed as a percentage.
is a measurement of the amount of blood that flows backward through a valve, expressed as a fraction of the total stroke volume
