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
What are quantitative features of severe IMR
EROA (mm2) > 30
Regurg volume > 60
+ enlargement of cardiac chambers/vessels
List quantitative features of severe TR
EROA (mm2) > 40mm2
> 45ml/beat of R vol
RV, RA, and Inferior vena cava dilation
What are quantitative findings for severe primary MR
EROA (mm2) > 40
R vol > 60
LV and LA enlargement
List quantitative features of secondary MR
EROA (mm2) = > 20
R vol > 30
List qualitative features of severe MR
fail leaflet/ruptured papillary muscle/large coaptation defect
central jet or eccentric jet adhering, swiring, and reaching the posterior wall of the left atrium
large flow convergence zone
Semi-quantitative > 7 mm vena contracta systolic pulmonary vein flow reversal E-wave dominant > 1.5 TVI mitra/TVI aortic > 1.4
List qualitative features of AR
abnormal/fail/large coaptation defect
large central jet, variable in eccentric jets
Dense CW
Holodiastolic flow reversal in descending aorta (EDV > 20 cm)
Semiquantitative
> 6 mm vena contracta width (mm)
Pressure half-time < 200 ms
List qualitative features of TR
abnormal fail/large coaptation defect
very large central jet or eccentric wall
Semiquantiative > 7 vena contracta systolic hepatic vein flow reversal E-wave dominant > 1 m/s PISA radius > 9 mm
What are TTE pericardial compression signs
LV septal displacement with respiration
Increased mitral inflow with expiration and reduction with inspiration
What are risk factors for esophageal injury in pt undergoing TEE
Previous esophageal injury throacic aortic aneurysm prlonged steroid use large LA advanced age previous thoracic irradiation
What is normal thickening of myocardium with contraction
> 40% wall thickening with systole
What is hypokinetic
< 30% wall thickening with systole
Define Akinetic and dyskinetic wall motion on echo
Akinetic < 10% wall thickening
Dyskinetic–segmental outward motion during systole (usually some thickening)
What are tamponade findings on echo
IVC dilation
invagination of the RA wall in diastole
expiratory collapse of the RV
Echo signs consistent with pericardial constriction
thickened perciardium > 6 mm
ventricular interaction: idicates a fixed peridcardial space with leftward septal shit (septal bounce)
decreased mitral inflow with inspiration
decreased pulmonic inflow with inspiration
increased TV inflow during inspiration
diastolic hepatic venous flow reversal with expiration
What is the significance of color on the colour-mapping Doppler
Blue Color represents flow away from the probe
Red color presents flow towards the probe
What is modified Bernoulli equation
Using this equation two difference pressure gradients can be calculated across a cardiac valve
Change in Pressure = 4V2 (squared)
a peak gradient : which is calculated from peal velocity
mean gradient: which is calculated from the mean velocity
What are two major assumptions of doppler-calculated gradients
All measurements assume linear flow—valvular stenosis produced trubulent flow
All measurements assume ultrasound beam is parallel to the direction of blood.
What is continuity equation
Based on the principle of conservation of mass, hence the flow of blood across the outflow tract of a chamber must be the same as the flow of blood across the valve of that chamber
Volume of blood flow = cross-sectional area (A) X velocity of blood
How can you measure Pulmonary artery systolic pressure by echocardiography
Use a modified Bernoullie equation
RVSP = 4 V2 + JVP
assuming there is no pulmonary stenosis, RVSP also represents the pulmonary artery systolic pressure (normally less then 25)
Define vena contracta
narrowest segment of regurgitant flow stream and typically occurs just beyond the reguritant orifice
What are echo risk factors for SAM
Septum > 15mm Small LV cavity Hyperdynamic LVEF 65% Aorto mitral angle < 120 Short coaptation-septal distance< 25 mm Too small annuloplasty ring Excessive height of posterior leaflet post repair
What is diastolic dysfunction
limitation of the ventricle to fill to normal end-diastolic volume without an abnormal increase in end-diastolic pressure at rest or during exercise
