Echo Stuff Flashcards
What is abnormal Longitudinal strain?
> -18% (like -17% onwards)
Name 9 criteria for Severe AR?
-Diastolic flow reversal in Ascending Aorta
-LVEDD > 65
-Reduced LVEF
-PHT < 200 msec
-Rvol > 50%
-RF > 60%
- VC > 65% in PS Long
- ERO > 0.3
-VC > 0.60
What are three features of Rheumatic mitral stenosis?
-thickening predominant at leaflet tips
-doming of the mitral leaflets in diastole which leads to the hockey stick sign
-Thickened chordae
Name 5 ways to assess MS severity?
-Planimetry: Tend to over measure, limited by image quality
-MG:
-Continuity equation: MVA = (Pi)(LVOT radius)^2 x VTI LVOT / VTI MVA
-PHT: MVA / SqRt
-PISA: (Pi)(r)2 x Aliasing Velocity x angle / Mitral Valve Velocity
How do you derive MVA by PHT?
MVA = 220/PHT
Name two things that will shorten PHT
-AR
-High LVEDP
Name something that will lengthen PHT?
Early post PMBC
How do you derive PHT?
0.29 x DT
How do you derive MVA by PISA?
MVA = (2(pi)(r^2) x (Alias Velocity)) / Vmax
What are the 4 components of the Wilkins score? What score is good?
- Valve mobility
- Valve thickening
- Valve calcification
- Subvalvular thickening
- < 8
What is the Carpentier classification?
-Type 1: Normal leaflet motion
-Type 2: Increased Leaflet mobility
-Type 3: Decreased Leaflet mobility
Name 3 characteristics of jet area that indicate severe MR?
- Jet > 10 cm^2
- > 40% LA area
- Jet swirling in the LA
4 indicators of Severe MR?
- VC > 0.7
-ERO > 0.4 cm^2
-RF > 50%
-RVol 60 cc
How to calculate ERO?
PISA = 2(Pi)(R^2) x Aliasing Velocity
ERO = PISA/MR velocity
What are two doppler parameters to indicate severe MR?
-E wave > 1.2 cm
-Dense triangular CW wave
What are 4 etiologies of Pulmonic regurgitation?
-Carcinoid
-Endocarditis
-Rheumatic
-Secondary Pulm Htn
What is the key hemodynamic principle in Constriction?
-Dissociation of intrathoracic and intrapericardial pressures with inspiration and expiration
-The negative intrathoracic pressure pulls wedge pressure below LV diastolic
What are 6 features of constriction on echo?
-MV/TV inflow by 25/40%
-Septal bounce > 8mm septal e prime
-Abnormal septal flattening with variation
-Pulmonary and hepatic vein reversal in diastole
-Plethoric IVC
-Thickened Pericardium
What are the 3 grades of diastolic dysfunction?
- Reduced relaxation with normal filling pressure
- Filling pressure starts to elevate
- Increased filling pressures
Diastology: E/e prime cut off
> 14
Septal and Lateral e velocity
< 7 and < 10 cm/s
TR velocity
2.8 m/s
LA volume for DD
34
What are three reasons that you can’t measure Diastology?
- Afib
-MAC - > Moderate MR
What are three echo features of myxomas?
-Found in all cavities of the heart (LA 75% of time) and not attached to valves
-narrow stalk
-mobile
How do you differentiate a Papillary Fibroeleastoma from Myxoma?
-Small size with stippled edge
-Finger like projections from the tumor
What are two echo features of Angiosarcoma?
-Echo dense mass that blurs with the usual tissue margins
-Associated with effusion 90% of time
What is a Lambl’s excrescence?
-Forms along closure margins of the valves, greater frequency with age ?degenerative
What is the cut off for mild, mod and severe PPM of AVR?
> 0.85
< 0.85
< 0.65
What is cut off for mild, moderate and severe PPM for the mitral valve?
> 1.2
< 1.2
< 0.9
What is the formula for RVSP?
RVSP = 4(V tr)^2 + RAP
What is formula for PADP?
PADP = 4 (V ePR)^2 + RAP
What is formula for mean PA pressure?
mPAP = 4(V peak PR)^2 + RAP
What is the W sign in PH?
Mmode through RVOT, signifies high RV afterload
What is rule of 60’s for PE?
Less then 60msec accel time, less than 60mmHg
In chornic pulmonary htn, the acceleration time shortens to less than 100 msec
Differential for high gradient across mitral prosthetic Valve?
-Thrombus
-Vegetation
-Pannus
-PPM
-MR (differentiate with supportive features (PHT, Pulmonary veins)
AVA VTI Continuity Equation
Modified Bernoulli Equation
MR PISA, ERO, Residual Volume Equation
Echo Qp/Qs
Stroke Volume and Cardiac Output
Review Echo criteria for CP diagnosis
Review algorithm for high gradient across mechanical mitral valve?
Review Diastology Algorithm part 2
Review Diastology algorithm part 1
What is restrictive features as per 2016 Diastology guidelines? (6)
-Mitral E/A > 2.5
-DT of E wave < 150 msec
-IVRT < 50 msec
-Septal and Lateral E velocities < 5 (but lateral still greater than Septal)
-LAE > 50
-E/e’ > 14
Review A-F of M Mode of Mitral valve leaflet
What is this and what does it represent?
B Bump
Elevated LVEDP (> 20mmhg)
What is shown here?
SAM (during systole)
What is this?
Rheumatic Mitral Stenosis (notice how anterior and posterior mitral leaflets move in unison)
What is this?
MMode demonstrating MVP
What is this?
-MVP (Late systolic regurgitation)
What is this?
LA Myxoma
Echodensity which is prolapsing into the LA
What Rhythm is this?
Atrial Fibrillation
What is shown here ? (MMode through Aortic Valve)
HoCM, mid systolic closure of Aortic Valve
What is shown here?
Constriction- Movement of the IVS with respiration
What is shown here?
Tamponade: LV End Diastole varies with inspiration (decreases) and Posterior Pericardial Effusion
What is shown here?
Flying W -> MMode through the RVOT showing that the Pulmonic valve closes/shutters half way through systole indicated Pulmonary Hypertension
Diagnosis?
CP- Annulus Paradoxus
Diagnosis?
CP- Diastolic reversal in Hepatic vein in expiration
Doppler of LVOT, what is shown here?
Pulsus alternans- Severe CMO
Doppler of LVOT, what is shown here?
Pulsus alternans- Severe CMO
What are 5 predictors of embolism in IE?
-Large vegetations > 10mm
-Highly mobile vegetations
-Anterior mitral valve leaflet
-Staph aureus
-Delay in appropriate antibiotic therapy
What are the variants of HCM morphology? (4)
-Reverse Curve Morphologic Variant
-Neutral Septal Morphologic Variant
-Sigmoid Septal Variant
-Apical Variant (Progression to aneurysm)
How to differentiate MR from LVOT doppler?
-MR is longer than LVOT
-MR is higher velocity that LVOT
-MR shape is less late peaking
What are 4 criteria for Diastolic Dysfunction?
The majority of:
-Septal E’ < 7 cm/s, Lateral E’ < 10 cm/s
-Average E/e’ > 14
-TR Velocity > 2.8 m/s
-LAVI > 34
What supports Grade 1 Diastolic dysfunction (Impaired relaxation, normal LA Pressure)
E/A < 0.8 + E < 50 cm/s
What supports Grade III diastolic dysfunction?
E/A > 2 (High LA filling pressure)
What supports Grade II diastolic dysfunction?
-E/A < 0.8 + E > 50 cm/s OR E/A 0.8 - 2 with 2/3 of the following:
-Average E/e’ > 14
-TR Velocity > 2.8 m/s
-LAVI > 34
What happens to E and A with Valsalva?
Both E and A decrease
What happens to E and A with Valsalva in Grade 2 diastolic dysfunction?
E/A goes from reduced to > 1
What Deceleration time is associated with poor survival in Atrial Fibrillation?
DT < 130 msec
How to differentiate between pathologic and functional obstruction using acceleration time in Aortic Valve Prosthetic valves?
-Jet Acceleration time > 100msec -> pathologic
< 100msec -> functional obstruction (Regurgitation, PPM, normal prosthesis)
What is the formula for Dimensionless Index?
DVI = LVOT Velocity / Prosthetic Velocity
How to use DVI to differentiate between pathologic Aortic Prosthetic Valve stenosis vs/ functional obstruction?
DVI < 0.25 -> pathologic
DVI > 0.3 -> functional obstruction
What is high velocity for prosthetic Aortic valve but AT < 100ms and indexed EOA < 0.65? What if indexed EOA > 0.85?
iEOA < 0.65 -> Severe PPM
iEOA > 0.85:
-If MG > 20 -> Pathologic Regurgitation
-If MG < 20 -> normal
What happens if you use Pressure Half Time method for mitral prosthesis
It significantly over estimates EOA
How to differentiate between mitral prosthetic stenosis vs. functional obstruction for Mitral prosthetic valve?
-Use Pressure Half time
If PHT > 130 msec -> pathologic obstruction
If PHT < 130 msec -> PPM, Tachycardia, High flow, Functional obstruction
Name 3 CV symptoms of Cardiac masses, and 3 systemic
-CV: Embolism, Arrhythmia, HF
-Systemic: Fever, Fatigue, Weight loss
Where is Angiosarcoma usually located and what is it usually associated with?
RA
Associated with pericardial effusion
Cytology is universally negative
What are 2 hallmarks of atrial myxomas?
-In the left or right atrium attached to the IAS
What is most common benign pediatric cardiac neoplasm?
Rhabdomyoma
What systemic syndrome is associated with myxomas? What about rhabdomyomas?
Myxoma: Carney Complex (Autosomal Dominant)
Rhabdomyomas: Tuberous Sclerosis
Name 5 masses usually attached to valves
-Endocarditis
-Thrombus
-Papillary Fibroelastoma
-Lambl’s excrescences
-Non bacterial thrombotic endocarditis
2 scenarios where you can’t use bernouli equation + RAP for PASP estimation?
-RVOT obstruction/PV stenosis
-Wide Open TR as velocity is typically low flow
What is RV enlargement measurement in basal diameter in Apical 4 chamber?
> 41 mm
What is this?
Cleft Mitral Valve
How to diagnose Coronary Sinus ASD?
Left arm saline bubble injection to uncover Left sided SVC
What is this on PLAX?
Membranous VSD
What is this on PSAX?
Subarterial VSD?
What is this seen on PSAX ?
Inlet VSD
What is this seen on PSAX at level of aortic valve?
Subarterial VSD
How to calculate RVSP in the setting of a VSD? (Or any Right to left shunt)
RVSP = SBP - 4(Velocity through VSD)^2
Example: SBP is 120mmhg, Velocity through VSD is 5 m/s
RVSP = 120 - 4(5)^2
RVSP = 120 - 100
RVSP = 20mmhg
What is shown here?
3 sign with Aortic Coarctation
What is shown here?
PW through abdominal aorta -> shows antegrade extension of diastolic flow associated with Aortic Coarctation
Review VSD anatomy
Review VSDs on Echo
What S/D ratio is consistent with high LA pressure?
< 1
