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PTE Masters + A Practical Approach to Transesophageal Echocardiography > Hemodynamic Calculations > Flashcards

Hemodynamic Calculations Flashcards

1
Q

What is volume equal to?

A

Area x Distance

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2
Q

What is the stroke volume equal to?

A

Cross sectional area (CSA) x Stroke Distance

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3
Q

Where is stroke volume calculated? (2 places)

A

LVOT or Aortic Valve

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4
Q

What does the accuracy of the stroke volume determination depend on?

A
  1. Parallel Alignment of U/S beam to blood flow
  2. Accurate determinations of vessel cross sectional area (CSA)
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5
Q

How do we calculate Stroke Volume?

A

Stroke Volume = (Area at LVOT or Aortic Valve) x Stroke Distance

Said another way:

SV = Area x Stroke Distance = CSA x TVI

Stroke distance = TVI (Time Velocity Intergral) = VTI

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6
Q

How would we measure CSA of LVOT to measure stroke volume?

A

Deep Transgastric Long Axis view with U/S Beam through Aortic Valve

  1. Measure LVOT
  2. Use (pi)*r2
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7
Q

How do you calculate Stroke Distance Logistically?

A
  1. Deep TG with doppler through Aortic Valve
  2. Measure negative deflection
  3. This will give you TVI = Stroke Distance
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8
Q

What is Qp / Qs mean?

A

Qp = Flow through Right side of heart (p = pulmonary)

Qs = Flow through the Left side of the heart (s = systemic)

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9
Q

How do we calculate Qp/Qs on echo?

A

SVPA / SVLVOT

SVPA = APA x TVIPA

SVLVOT = ALVOT x TVILVOT

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10
Q

What TEE view do we use to calculate the Stroke Volume through the PA?

A

Mid-Esophageal Ascending Aorta Short Axis

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11
Q

What TEE view do we use to calculate Stroke Volume of the LVOT?

A

Mid Esophageal Long Axis to get Area of the LVOT

Deep TG Short Axis to get TVILVOT

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12
Q

How close do you want to measure the LVOT from the aortic valve?

A

Stay within 1 cm (Distance changes the further you go away from that)

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13
Q

What is the derivation to arrive at the Regurgitant Volume equation?

Hint- continuity equation

A

Volume in = Volume out

Diastolic LV inflow = Systolic LV outflow = (SV forward + Regurgitant Volume)

SVMV inflow = SVAV + Regurgitant VolumeMV

Regurgitant VolumeMV = SVAV - SVMV inflow

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14
Q

How do you calculate SVMV?

A

AMV x TVIMV

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15
Q

What is the cutoff for Mild MR based on Regurgitant Volume?

A

<30 mL

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16
Q

What is the cutoff for Moderate MR based on Regurgitant Volume?

A

30 - 59 mL

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17
Q

What is the cutoff for Severe MR based on Regurgitant Volume?

A

> 60 mL

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18
Q

What is the formula for regurgitant volume?

Hint- continuity equation

A

SVMV - SVLVOT

SV<strong>MV</strong> = AMV x TVI MV inflow

SVLVOT = ALVOT x TVILVOT

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19
Q

What are all the ways that the Area of the Mitral valve can be calculated in order to obtain SVMV?

A

220 / Pressure Half Time

760 / Decelaration TIme
PISA
Continuity Equation

Pi * r2

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20
Q

What is the regurgitant fraction?

What is the equation for this?

A

Backwards Flow / Total Flow

Regurgitant Fraction (RF) = Regurgitant Volume / SVMV Inflow

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21
Q

What is the cutoff for Mild MR based on Regurgitant Fraction?

A

<30%

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22
Q

What is the cutoff for Moderate MR based on Regurgitant Fraction?

A

30-49%

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23
Q

What is the cutoff for Severe MR based on Regurgitant Fraction?

A

>50%

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24
Q

What is the regurgitant orifice area?

A

Area of the hole through which regurgitation occurs

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25
Q

regurgitant orifice area equation

A

Volume = Area x Distance

Regurgitant Orifice Area = Regurgitant Volume / TVI Mitral Valve

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26
Q

What is the cutoff for Mild MR based on Regurgitant Orifice Area?

A

< 0.2 cm2

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27
Q

What is the cutoff for Moderate MR based on Regurgitant Orifice Area?

A

0.2 - 0.39 cm2

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28
Q

What is the cutoff for Severe MR based on Regurgitant Orifice Area?

A

> 0.4 cm2

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29
Q

What do we use to calculate intracardiac pressures?

A

Change in Pressure (Delta) = 4V2

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30
Q

How do you estimate RA pressure?

A

IVC size

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31
Q

What is the estimated Right Atrial Pressure for an IVC of <1.5 cm and Collapses with Sniff?

A

0 - 5 mmHg

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32
Q

What is the estimated Right Atrial Pressure for an IVC of 1.5-2.5 cm and Decreases >50%?

A

5 - 10 mmHg

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33
Q

What is the estimated Right Atrial Pressure for an IVC of 1.5-2.5 cm and Decreases <50%?

A

10 - 15 mmHg

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34
Q

What is the estimated Right Atrial Pressure for an IVC of >2.5 cm and Decreases <50%?

A

15 - 20 mmHg

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35
Q

What is the estimated Right Atrial Pressure for an IVC of >2.5 cm and No change with Sniff?

A

>20 mmHg

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36
Q

What is the RV Diastolic Pressure going to equal?

A

RVDP = RAP

*Unless Tricuspid Stenosis is present

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37
Q

To calculate RVSP, What view do we use?

A

Mid-esophageal 4 chamber with U/S beam through tricuspid valve

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38
Q

What is the equation for RVSP?

A

Change in Pressure = 4*V2

RVSP - RAP = 4 (Velocity of Max TR Jet)2

*Rearrange equation*

RVSP = 4 (Velocity of Max TR Jet)2 + RAP

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39
Q

What is the equation for Pulmonary Artery Systolic Pressure?

*What is the caveat*

A

PASP = RVSP - Change in Pressure (Pulmonic Stenosis)

*Caveat is Pulmonic Stenosis in which you have to subtract the gradient across the pulmonic valve

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40
Q

How do we calculate the Main Pulmonary Artery Mean Pressures?

A

Not done often**

Change in P = 4 V2

PAMP - RVDP = 4 (VPI early)2

PAMP = 4 (VPI early)2 + RVDP

PAMP = 4 (VPI early)2​ + RAP

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41
Q

When do you use VPI early and when do you use VPI late?

A

Early = PA Mean

PAMP = 4 (VPI Early)2 + RAP

Late = PA Diastolic

PADP = 4 (VPI Late)2 + RAP

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42
Q

How do we estimate Left Atrial Pressure?

Equation

A

Measure this from the velocity of an MR Jet

Change in Pressure = 4 V2

LVSP - LAP = 4 (VMR)2

*LVSP can be substituted by SBP*

LAP = SBP - 4 (VMR)2

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43
Q

If you have a VSD, How do you calculate RVSP?

A

Change in Pressure = 4V2

LVSP - RVSP = 4 (VVSD)2

RVSP = LVSP - 4 (VVSD)2

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44
Q

What is Dp/Dt?

A

Isovolumetric rate of LV Pressure rise

Said another way:

Rate of LV pressure rise during isovolumetric contraction of the LV

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45
Q

What is Dp/Dt calculated as?

A

Slope of LV Pressure rise from 4-36 mmHg (VMR = 1 to VMR = 3 m/s)

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46
Q

What is Dp/Dt dependent on?

A

Preload

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47
Q

What is Dp/Dt independent of?

A

Afterload

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48
Q

What is the equation for calculating Dp/Dt?

A

Use Change in Pressure = 4V2

With Mitral Regurgitation: Change in P = (PLV - PLA) = 4 (VMR)2

PLV = 4 (VMR)2 + PLA

Then substitute

VMR 1 = 4 so PLV = 4 + PLA

VMR 3 = 36 so PLV = 36 + PLA

Change in P / Change in T = 32/ Change in T

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49
Q

What is the Dp/Dt for this picture?

Change in Time is 0.06

A

Change in P = 32 / 0.06

533 mmHg

A normal value for dP/dt, or the rate of change in pressure over time, is greater than or equal to 1,000–1,200 mmHg/s. A value below 500 mmHg/s indicates severe systolic dysfunction.

dP/dt is a measure of the rate at which pressure rises in the left ventricle during systole. It’s a common index of contractility, and can be used to assess the function of the left ventricle.

Here are some other dP/dt values:
Borderline: 800–1,200 mmHg/s
Reduced: Less than 800 mmHg/s
Severely reduced: Less than 500 mmHg/s

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50
Q

The peak velocity is 280 cm/sec

Given BP of 120/80, Calculate RVSP

A
  1. Convert 280 cm/sec = 2.8 m/sec
  2. Realize its a VSD
  3. RVSP = LVSP - 4 (VVSD)2
  4. RVSP = 120 - 31 = 88 mmHg
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51
Q

What Tricuspid Valve Leaflets are seen here?

A

Left = Septal / Posterior

Right = Anterior

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52
Q

What is the green circle at?

A

Right Atrial Appendage

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53
Q

What pressure can be calculated from the modified bicaval view?

A

This is the Tricuspid valve shown here with an U/S beam through it.

You can calculate:

RVSP using Bernoulli (Change in Pressure) = 4 * (VTR JET)2 + RAP

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54
Q

RV Systolic Pressure = Pulmonary Systolic Pressure in the absence of what?

A

Pulmonic Stenosis

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55
Q

What TR peak velocity is indicative of elevated Left Atrial Pressure?

What TR peak velocity is indicative of elevated Diastolic Dysfunction?

A

>2.8 m/sec

*Commit to memory*

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56
Q

What is normal Mitral E/A ratio?

A

>/= 0.8

57
Q

What is impaired Grade 1 Diastolic Dysfunction for Mitral E/A ratio?

A

= 0.8

58
Q

What is impaired Grade 2 Diastolic Dysfunction Mitral E/A ratio?

A

>0.8 and <2

59
Q

What is impaired Grade 3 Diastolic Dysfunction for Mitral E/A ratio?

A

>2

60
Q

What the average E/e’ ratio for normal diastolic function?

A

<10

61
Q

What the E/e’ ratio for Grade 1 diastolic function?

A

<10

62
Q

What the E/e’ ratio for Grade 2 diastolic function?

A

10-14

63
Q

What the E/e’ ratio for Grade 3 diastolic function?

A

>14

64
Q

What the Peak TR V (m/sec) for normal diastolic function?

A

<2.8 m/sec

65
Q

What the Peak TR V (m/sec) for Grade 1 diastolic function?

A

< 2.8 m/sec

66
Q

What the Peak TR V (m/sec) for Grade 2 diastolic function?

A

>2.8 m/sec

67
Q

What the Peak TR V (m/sec) for Grade 3 diastolic function?

A

> 2.8 m/sec

68
Q

What is the LA volume index for normal diastolic function?

A

< 34 mL/m2

69
Q

What is the LA volume index for Grade I diastolic dysfunction?

A

“NI” or increased

70
Q

What is the LA volume index for Grade 2 diastolic dysfunction?

A

> 34 mL/m2

71
Q

What is the LA volume index for Grade 3 diastolic dysfunction?

A

>34 mL/m2

72
Q

In patients with a normal Ejection fraction, what are the 4 determinants that factor into diastolic dysfunction diagnosis?

A
  1. Average E/e’ >14
  2. Septal e’ < 7 cm/sec or Late e’ <10 cm/sec
  3. TR Velocity >2.8 m/sec
  4. LA volume index > 34 mL/m2
73
Q

What is the criteria for determining Normal Diastolic Dysfunction for patients with normal LVEF?

A

<50% positive

  1. Average E/e’ >14
  2. Septal e’ < 7 cm/sec or Late e’ <10 cm/sec
  3. TR Velocity >2.8 m/sec
  4. LA volume index > 34 mL/m2
74
Q

What is the criteria for intermediate determination for diastolic dysfunction for patients with normal LVEF?

A

50% positive

  1. Average E/e’ >14
  2. Septal e’ < 7 cm/sec or Late e’ <10 cm/sec
  3. TR Velocity >2.8 m/sec
  4. LA volume index > 34 mL/m2
75
Q

What is the criteria for determining diastolic dysfunction for patients with normal LVEF?

A

>50% positive

  1. Average E/e’ >14
  2. Septal e’ < 7 cm/sec or Late e’ <10 cm/sec
  3. TR Velocity >2.8 m/sec
  4. LA volume index > 34 mL/m2
76
Q

What are the criteria for a one step determination for Grade 1 Diastolic Dysfunction?

A

E/A < 0.8

AND

E < 50 cm/sec

77
Q

What are the criteria for a one step determination for Grade 3 Diastolic Dysfunction?

A

E/A >/= 2

78
Q

What E/A and E criteria are required to find more information before determining diastolic dysfunction criteria?

A

E/A = 0.8 and E > 50 cm/sec

OR

E/A >0.8 but <2

79
Q

If you have:

E/A = 0.8 and E > 50 cm/sec

OR

E/A >0.8 but <2

What additional 3 criteria need to be evaluated?

A
  1. Average E/e’ >14
  2. TR velocity > 2.8 m/sec
  3. LA Volume Index >34 mL/m2
80
Q

What is the pathway for determining criteria for Grade 1 diastolic function, Grade II Diastolic function or indeterminate?

A
  1. Average E/e’ >14
  2. TR velocity > 2.8 m/sec
  3. LA Volume Index >34 mL/m2

If 2 of above negative = Grade 1 Diastolic Dysfunction

If 1 positive, 1 negative = Cannot determine LAP and Diastolic Dysfunction

If 2 positive = Grade II Diastolic Dysfunction

81
Q

See image for question

A

6.8 L/min

82
Q

What valve is this?

What is the Peak instantaneous pressure across the valve if the V-peak = 100 cm/sec

A

Pulmonic valve

4 mmHg

83
Q

What is the Mean pressure change in mild mitral stenosis?

A

<5 mmHg

84
Q

What is the Mean pressure change in moderate mitral stenosis?

A

5 - 10 mmhg

85
Q

What is the Mean pressure change in severe mitral stenosis?

A

>10 mmHg

86
Q

What is the normal PHT for the mitral valve?

A

30 - 89 msec

87
Q

What is the PHT for mild mitral stenosis?

A

90 - 150 msec

88
Q

What is the PHT for moderate mitral stenosis?

A

150 - 219 msec

89
Q

What is the PHT for severe mitral stenosis?

A

>220 msec

90
Q

What is the normal Mitral valve Area?

A

>2.5 cm2

91
Q

What is the Mitral Valve area in mild mitral stenosis?

A

1.6 - 2.5 cm2

92
Q

What is the Mitral Valve area in moderate mitral stenosis?

A

1.0 - 1.5 cm2

93
Q

What is the Mitral Valve area in severe mitral stenosis?

A

<1.0 cm2

94
Q

What is the formula for Mitral valve area if you are given the PHT?

A

MVA = 220 / PHT

95
Q

What equation relates the Left Atrial Pressure, Right atrial pressure and VPFO?

A

LAP - RAP = 4 (VPFO)2

96
Q

What is Epstein Anomaly associated with?

A
  1. WPW (SVT)
  2. Secundum ASD
97
Q

What is the normal values of:

  1. Ejection Fraction?
  2. Fractional Area Contraction?
  3. Fractional Shortening?
A

EF > FAC > FS

EF = >55%

FAC = >36% (36-64%

FS = >25%

98
Q

What is the formula for velocity of circumferential shortening?

A

VcF = FS* / *ET = [(EDD - ESD) / EDD] * ET

ET = Ejection Time

FS = Fractional Shortening

The velocity of circumferential fiber shortening (VCF) is a measurement of the rate at which the left ventricle of the heart shortens during ejection. It’s a measure of myocardial performance and is sensitive to the contractile state of the heart.

VCF is calculated by measuring the degree of fiber shortening and the duration of the ejection phase. It can be derived from M-mode or two-dimensional echocardiograms.

VCF is dependent on left ventricular loading conditions, such as preload and afterload, and heart rate. To increase the reliability of VCF as a parameter of myocardial function, it can be normalized to heart rate. This normalized value is called the relative velocity of contraction (RVC). RVC is independent of heart rate and has less physiological variation than VCF

99
Q

What is the Mitral Valve Area equation using Pressure Half Time?

A

MVA = 220 / PHT

100
Q

What is the LVSP equal to?

A

SBP + Aortic valve gradient

101
Q

If you have a Systolic BP of 120 and a peak velocity across the aortic valve of 0.5 m/s, what other information is needed to calculate LAP?

A

Peak velocity of MR Jet

Change in Pressure = (LVSP - LAP) = 4 (VMR)2

102
Q

If given PFO velocity of 78 m/s, CVP of 14, what is the LAP?

A

LAP = 11.6 mmHg

103
Q

If given VSD peak velocities and the Blood Pressure. What is the RVSP?

A

Change in P = LVSP - RVSP = 4 (VVSD)2

LVSP = Aortic Blood Pressure (Systolic)

104
Q

If you have a VSD as a sequelae from an MI, what do you need to be cautious of on induction?

A

Oxygen and Hyperventilation

  1. Oxygen lowers PVR and can increase pulmonary blood flow
  2. Increase left to right shunting
  3. Decrease systemic blood flow and decrease systemic C.O.
  4. Worsening heart failure

As soon as ETT is in, turn down to room air

105
Q

Given VSD peak velocity of 3.73 m/sec and a BP of 110/80

What is the RVSP?

A

Delta P = 4 V2

Delta P = LVSP - RVSP = 4 (VVSD)2

RVSP = LVSP - 4 (VVSD)2

RVSP = 110 - 4(3.73)2 = 110 mmHg - 56 = 54 mmHg

LVSP = SBP (In absence of aortic stenosis)

106
Q

If you have a VSD as a sequelae from an MI, what monitors are especially important to have?

A

SvO2 = Pulmonary artery catheter

107
Q

You have a VSD patient with a PA Catheter in the ICU you have hypotension in setting of increased SvO2 from 70-99, what is the diagnosis until proven otherwise?

A

VSD patch has ruptured

108
Q

What are the parameters you need to measure Qp (Flow through the pulmonary circuit?

A

Ascending Aorta Short Axis to get:

  1. PA diameter
  2. VTI through RVOT
109
Q

What is seen in the coronary sinus with severe TR?

A

Systolic Flow reversal in the coronary sinus

110
Q

What is seen in the Hepatic Veins here?

A

Pulsed-wave Doppler of the hepatic veins demonstrating systolic flow reversal.

ASV wave in ASVD wave are merged

111
Q

What is the Peak velocity with severe TR?

A

Gradient actually similar between atria

Paradoxical

112
Q

What is TR jet vena contracta with severe TR?

A

>7 mm

113
Q

label these waves

A

A wave - a result of retrograde atrial systolic flow. It is seen below the baseline as blood flow is away from the transducer.

S wave - a result of antegrade ventricular systolic flow. It is seen above the baseline as blood flow is towards the transducer.

V wave - a result of retrograde end-ventricular systolic flow. It is seen below the baseline as blood flow is away from the transducer.

D wave - a result of antegrade ventricular diastolic flow. It is seen above the baseline as blood flow is towards the transducer.

114
Q

What is the formula for EF?

A

(EDV - ESV) / EDV

115
Q

What is the formula for stroke volume?

A

EDV - ESV

116
Q

What is the formula for velocity ratio when doing aortic valve calculations?

A

AreaAV / AreaLVOT = VelocityLVOT / VelocityAV

117
Q

What is the defintion of aortic sclerosis that does not meet mild AS (normal) on aortic jet velocity?

A

< 2.5 m/s

118
Q

Aortic Jet Velocity:

Mild AS

A

2.6 - 2.9 m/s

119
Q

Aortic Jet Velocity:

Moderate AS

A

3 - 4 m/s

120
Q

Aortic Jet Velocity:

Severe AS

A

>4 m/s

121
Q

Mean Gradient per American Guidelines

Mild AS

A

<20 mmHg

122
Q

Mean Gradient per American Guidelines

Moderate AS

A

20 - 40 mmHg

123
Q

Mean Gradient per American Guidelines

Severe AS

A

>40 mmHg

124
Q

AVA by continuity equation for:

Mild AS

A

>1.5 cm2

125
Q

AVA by continuity equation for:

Moderate AS

A

1.0 - 1.5 cm2

126
Q

AVA by continuity equation for:

Severe AS

A

<1.0 cm2

127
Q

Indexed AVA

Mild AS

A

>0.85 cm2/m2

128
Q

Indexed AVA

Moderate AS

A

0.6 - 0.85 cm2/m2

129
Q

Indexed AVA

Severe AS

A

<0.6 cm2/m2

130
Q

Velocity Ratio

Mild AS

A

>0.5

131
Q

Velocity Ratio

Moderate AS

A

0.25 - 0.5

132
Q

Velocity Ratio

Severe AS

A

< 0.25

133
Q

What can be caculated from Peak Early Velocity of the aortic valve?

A

**Check this answer with an attending**

134
Q

What can be caculated from Peak Late Velocity of the aortic valve in aortic insufficiency?

A

LVEDP

135
Q

Given a BP of 100/55, what is the LVEDP when you have a peak late velocity of 3.38 m/sec?

A

Change in Pressure = 4V2 = AoDP - LVEDP

4 (VAI LATE) = 4(3.38)2

LVEDP = 55mmHg - 45.7 mmHg

LVEDP = 9.3 mmHg

136
Q

What is helpful when using the dimensionless index (velocity ratio) for BMI considerations?

A

Size independent

137
Q

What is the difference of LVOT area in 2d (ME AV LAX) vs. 3d?

A

2D = Underestimates LVOT area = Overestimate the degree of stenosis

2D = D1 but this is more of an ellipse

138
Q

This card marks questions on the practice exam (No question)

A

This card marks questions on the practice exam (No answer)

139
Q
A

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