Echo questions Flashcards
What is diastolic heart failure
defined as a condition in which filling of the LV is impeded resulting in symptoms of low cardiac output, elevated LV filling pressure or both.
What are 4 phases of diastole
Isovolumetric relaxation time (IVRT)–closure AV to open of MV
Rapid ventricular filling (E wave velocity) MV opens, accumulating blood from LA LV increasing LVP
Diastasis (slope of filling)
Atrial contraction
What are patterns that diastolic dysfunction can present itself
impaired relaxation–reduced LV relaxation rate but relatively normal compliance and filling pressure
Pseudo normal—combined pattern of abnormal relaxation and restrictive physiology.
Restrictive–profound abnormalities of LV relaxation, compliance and mardedly increased filling pressure
Normal filling pattern
List 4 echocardiographic grades of diastolic dysfunction
Grade 1: abnormal relative E < A
Grade 2: Pseudonormal relaxation E > A
Grade 3: reversible restrictive filling E»_space; A
Grade 4: fixed restrictive filling E»_space;>A
Components of mitral valve inflow pattern
E = early wave represents early diastolic left ventricular phase
A (Atrial) - late diastolic ventricular filling phase associated with left atrial contraction
AT = accerleration time occurs from the onset of mitral diastolic time to the peak of the E wave
DT = deceleration time occurs from the peal of the E wave to the end of the early mitral flow
Normal is 1-2:
Phil Jones 5 measurements of Diastolic dysfunction
- Transmitral E wave deceleration time
- Isolvolumic relaxation time
- transmitral E:A ratio
- Ratio of transmitral A wave duration to pulmonary atrial reversal wave duration
- Pulmonary vein S:D ratio
What 4 tests are on the echo are you going to ask for when it comes to diastolic dysfunction
Transmitral doppler flow
check for DT
E and A ratio (if E < A then you have a problem)
Pulmonary Vein Flow Dopper
A blunted pulmonary vein flow pattern is found in diastolic dysfunction
Tissue Doppler imaging
displays the velocities of the myocardium during contraction and relaxation
Color M mode transmitral flow
Dr. Mcarthry diastolic dysfunction
Tissue Doppler imaging - reduction in the ventricular myocardial E’ relaxation velocity, reversal of the E’:A’ ratio (mirroring the mitral E:E ratio) and a E:E’ ratio greater than 15 are also indicators.
The presence of left atrial dilation is usually seen and reflects chronic elevation in filling pressures which accompanies diastolic dysfunction.
LV hypertrophy is also usually present.
What is “E”
This is deceleration time from peak to baseline
If > 24 ms is impaired relaxation
What is IVRT
Isolcolumetric relaxation time
if > 90ms its impaired relaxation
What are features of diastolic dysfunction
Elevated filling pressure (LVEDP > 16mm Hg) or PCWP * Done in Cath
Rate of LV myocardial relaxation is reflected by monoexpoentioal course of LV pressure fall, assuming (R = 0.97). to amonoexponential pressure decay.
Tau is a time constant that is widely accepted invasive measure of the rate of LV relaxation.
T > 48 ms
Isovolumetric relaxation time
Diastolic trans-mitral valve blood flow (E wave = early diastolic filling A = atrial contraction
E wave > A wave 1.5 to 1.0 ratio
If E to A < 1.0 then stiff heart and take long to relax
Really high E to A ratio > 2.0
What test can evaluate diastolic dysfunction
Brain Natriuretic peptide levels can be predictive.
If really high > 900s then both
if 500 think systolic
if low then 300s then systolic
describe diastolic filling issues
Changes in the passive component of diastole (shift of end-diastolic pressure-volume relationship (EDPVR). A left ward/upward shifted EDPVR (decreased ventricular capacitance results in a need for increased filling pressure to achieve filling volumes necessary for the heart to generate a normal stroke volume and blood pressure.
What is principle for Dopppler in diastolic heart failure
Pulse-waved Doppler tracing of mitral inflow are frequently used to study LV filling.
The normal filling velocity in early diastole is 1m/s if active relaxation is slowed early inflow is slower and loast for a longer duration.
This is responsible for the E/A reversal seen in pt.
What is Tissue Doppler
Newer, sophisticated technique to evaulate LV filling dynamics
directly measure the velocity of myocardial displacment as the LV expands in diastole.
The tissue velocity measured durning early filling (E-prime) can be considered a surrogate marker for tau
The ratio of of peak early transmitral flow velocity (E) to the peak early myocardial tissue velocity E-prime) is frequently cited as convincing evdience of myocardial diastoluc dysfunction.
What is an advantage of a Valsalva maneuver for assessing diastolic function
In cardiac patients a decrease of >50% in the E/A ratio is highly specific for increased LV filling pressure.
A smaller magnitude of change does not always indicated normal diastolic function.
What is Isovolumic relation time
when myocardium relaxation is impaired, LV pressure falls slowly, which results in a longer time before it drops the LA pressure.
Therefore, mitral opening is delayed and IVRT is prolonged.
What are main indicators of abdnormal relaxation
IVRT
Isvolumetric or early diastolic annulur motion or LV strain
Main indicators of reduced operating compliance
DR of Mitral E velocity
A-wave transit time
ratio of VEDP to LV end-diastolic volume
surrogates of of increased LVEDP
mitral A-wave duration
reduced A prime
and prolonged Ar during in pulmonary venous flow
What are indicators of early diastolic LV and LA pressures
E/eprime ration
DR of mitral E velocity in patients withe decpressed EF
What are the standard 2D echo views
Parasternal long axis Parasternal short axis Apical 4 chamber Apical five chamber apical long axis two chamber view subcostal suprasternal right parasternal view
What is a grading system for aortic atheroma
Grade 1: normal
Grade 2: intimal thickening
Grade 3 Protrudes < 5 mm into aortic lumen, irregular, sessile
Grade 4: protrudes > 5 mm into aortic lumen, irregular, sessile
Grade 5: mobile atheroma of any size
4 and 5 are associated with stroke
What are TEE findings of ischmic MR
Central MR
Dilated LV
MItral annulus dilated
posterior and apical displaced papillary muscle
decreased posterior medial annular angle (could be papillary muscle)
Tethering of mitral leaflet
How do you identify true and false lumen during dissection
True smaller Expands during systole color prominent False larger expands during diastole color less prominent clot/smoke present
What are the images for TTE
Parasternal
Apical
Subcostal
Suprasternal
