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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
regurgitant orifice area equation
Volume = Area x Distance Regurgitant Orifice Area = Regurgitant Volume / TVI Mitral Valve
26
What is the cutoff for **Mild MR** based on *_Regurgitant Orifice Area_*?
\< 0.2 cm2
27
What is the cutoff for **Moderate MR** based on *_Regurgitant Orifice Area_*?
0.2 - 0.39 cm2
28
What is the cutoff for **Severe MR** based on *_Regurgitant Orifice Area_*?
\> 0.4 cm2
29
What do we use to calculate intracardiac pressures?
Change in Pressure (Delta) = 4V2
30
How do you estimate RA pressure?
IVC size
31
What is the estimated Right Atrial Pressure for an **IVC of \<1.5 cm** and **Collapses with Sniff**?
0 - 5 mmHg
32
What is the estimated Right Atrial Pressure for an IVC of **1.5-2.5 cm** and **Decreases \>50%**?
5 - 10 mmHg
33
What is the estimated Right Atrial Pressure for an IVC of **1.5-2.5 cm** and **Decreases \<50%**?
10 - 15 mmHg
34
What is the estimated Right Atrial Pressure for an **IVC of \>2.5 cm** and **Decreases \<50%**?
15 - 20 mmHg
35
What is the estimated Right Atrial Pressure for an **IVC of \>2.5 cm** and *_No change with Sniff_*?
**\>20 mmHg**
36
What is the RV Diastolic Pressure going to equal?
RVDP = RAP \*Unless Tricuspid Stenosis is present
37
To calculate RVSP, What view do we use?
Mid-esophageal 4 chamber with U/S beam through tricuspid valve
38
What is the equation for RVSP?
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**
39
What is the equation for Pulmonary Artery Systolic Pressure? \*What is the caveat\*
**PASP = RVSP - Change in Pressure (Pulmonic Stenosis)** \*Caveat is Pulmonic Stenosis in which you have to subtract the gradient across the pulmonic valve
40
How do we calculate the Main Pulmonary Artery Mean Pressures?
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**
41
When do you use VPI early and when do you use VPI late?
Early = PA Mean **PAMP = 4 (VPI Early)2 + RAP** Late = PA Diastolic **PADP = 4 (VPI Late)2 + RAP**
42
How do we estimate **Left Atrial Pressure**? Equation
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**
43
If you have a VSD, How do you calculate RVSP?
Change in Pressure = 4V2 LVSP - RVSP = 4 (VVSD)2 RVSP = LVSP - 4 (VVSD)2
44
What is Dp/Dt?
I**sovolumetric rate of LV Pressure** rise Said another way: **Rate of LV pressure rise during *_isovolumetric contraction_* of the LV**
45
What is Dp/Dt calculated as?
Slope of LV Pressure rise from 4-36 mmHg (VMR = 1 to VMR = 3 m/s)
46
What is Dp/Dt dependent on?
Preload
47
What is Dp/Dt independent of?
Afterload
48
What is the equation for calculating Dp/Dt?
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_*
49
What is the **Dp/Dt** for this picture? Change in Time is 0.06
Change in P = 32 / 0.06 ## Footnote **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
50
The peak velocity is 280 cm/sec Given BP of 120/80, Calculate RVSP
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**
51
What Tricuspid Valve Leaflets are seen here?
Left = Septal / Posterior Right = Anterior
52
What is the green circle at?
Right Atrial Appendage
53
What pressure can be calculated from the modified bicaval view?
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**
54
RV Systolic Pressure = Pulmonary Systolic Pressure in the absence of what?
**Pulmonic Stenosis**
55
What TR peak velocity is indicative of elevated Left Atrial Pressure? What TR peak velocity is indicative of elevated Diastolic Dysfunction?
**\>2.8 m/sec** **\*Commit to memory\***
56
What is normal Mitral E/A ratio?
\>/= 0.8
57
What is impaired Grade 1 Diastolic Dysfunction for Mitral E/A ratio?
= 0.8
58
What is impaired Grade 2 Diastolic Dysfunction Mitral E/A ratio?
\>0.8 and \<2
59
What is impaired Grade 3 Diastolic Dysfunction for Mitral E/A ratio?
\>2
60
What the average E/e' ratio for normal diastolic function?
\<10
61
What the E/e' ratio for Grade 1 diastolic function?
\<10
62
What the E/e' ratio for Grade 2 diastolic function?
10-14
63
What the E/e' ratio for Grade 3 diastolic function?
**\>14**
64
What the Peak TR V (m/sec) for normal diastolic function?
\<2.8 m/sec
65
What the Peak TR V (m/sec) for Grade 1 diastolic function?
\< 2.8 m/sec
66
What the Peak TR V (m/sec) for Grade 2 diastolic function?
\>2.8 m/sec
67
What the Peak TR V (m/sec) for Grade 3 diastolic function?
\> 2.8 m/sec
68
What is the LA volume index for normal diastolic function?
\< 34 mL/m2
69
What is the LA volume index for Grade I diastolic dysfunction?
"NI" or increased
70
What is the LA volume index for Grade 2 diastolic dysfunction?
\> 34 mL/m2
71
What is the LA volume index for Grade 3 diastolic dysfunction?
\>34 mL/m2
72
In patients with a normal Ejection fraction, what are the 4 determinants that factor into diastolic dysfunction diagnosis?
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
What is the criteria for determining Normal Diastolic Dysfunction for patients with normal LVEF?
**\<50% positive** ## Footnote 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
What is the criteria for intermediate determination for diastolic dysfunction for patients with normal LVEF?
**50% positive** ## Footnote 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
What is the criteria for determining diastolic dysfunction for patients with normal LVEF?
**\>50% positive** ## Footnote 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
What are the criteria for a one step determination for Grade 1 Diastolic Dysfunction?
**E/A < 0.8** AND **E < 50 cm/sec**
77
What are the criteria for a one step determination for Grade 3 Diastolic Dysfunction?
**E/A \>/= 2**
78
What E/A and E criteria are required to find more information before determining diastolic dysfunction criteria?
**E/A = 0.8** and **E \> 50 cm/sec** OR **E/A \>0.8** but **\<2**
79
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?
1. Average E/e' \>14 2. TR velocity \> 2.8 m/sec 3. LA Volume Index \>34 mL/m2
80
What is the pathway for determining criteria for Grade 1 diastolic function, Grade II Diastolic function or indeterminate?
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
See image for question
6.8 L/min
82
What valve is this? What is the Peak instantaneous pressure across the valve if the V-peak = 100 cm/sec
Pulmonic valve 4 mmHg
83
What is the Mean pressure change in mild mitral stenosis?
\<5 mmHg
84
What is the Mean pressure change in moderate mitral stenosis?
5 - 10 mmhg
85
What is the Mean pressure change in severe mitral stenosis?
\>10 mmHg
86
What is the normal PHT for the mitral valve?
30 - 89 msec
87
What is the PHT for mild mitral stenosis?
90 - 150 msec
88
What is the PHT for moderate mitral stenosis?
150 - 219 msec
89
What is the PHT for severe mitral stenosis?
\>220 msec
90
What is the normal Mitral valve Area?
\>2.5 cm2
91
What is the Mitral Valve area in **mild** mitral stenosis?
1.6 - 2.5 cm2
92
What is the Mitral Valve area in **moderate** mitral stenosis?
1.0 - 1.5 cm2
93
What is the Mitral Valve area in **severe** mitral stenosis?
\<1.0 cm2
94
What is the formula for Mitral valve area if you are given the PHT?
MVA = 220 / PHT
95
What equation relates the Left Atrial Pressure, Right atrial pressure and VPFO?
LAP - RAP = 4 (VPFO)2
96
What is Epstein Anomaly associated with?
1. WPW (SVT) 2. Secundum ASD
97
**What is the normal values of:** 1. Ejection Fraction? 3. Fractional Area Contraction? 2. Fractional Shortening?
*_EF \> FAC \> FS_* EF = **\>55%** FAC = **\>36%** (36-64% FS = **\>25%**
98
What is the formula for velocity of circumferential shortening?
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
What is the Mitral Valve Area equation using Pressure Half Time?
MVA = 220 / PHT
100
What is the LVSP equal to?
**SBP** + **Aortic valve gradient**
101
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?
**Peak velocity of MR Jet** Change in Pressure = (LVSP - LAP) = 4 (VMR)2
102
If given PFO velocity of 78 m/s, CVP of 14, what is the LAP?
**LAP = 11.6 mmHg**
103
If given VSD peak velocities and the Blood Pressure. What is the RVSP?
Change in P = LVSP - **RVSP** = 4 (VVSD)2 LVSP = Aortic Blood Pressure (Systolic)
104
If you have a VSD as a sequelae from an MI, what do you need to be cautious of on induction?
**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
Given VSD peak velocity of 3.73 m/sec and a BP of 110/80 What is the RVSP?
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
If you have a VSD as a sequelae from an MI, what monitors are especially important to have?
**SvO2** = Pulmonary artery catheter
107
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?
VSD patch has ruptured
108
What are the parameters you need to measure Qp (Flow through the pulmonary circuit?
**Ascending Aorta Short Axis to get:** 1. PA diameter 2. VTI through RVOT
109
What is seen in the coronary sinus with severe TR?
Systolic Flow reversal in the coronary sinus
110
What is seen in the Hepatic Veins here?
Pulsed-wave Doppler of the hepatic veins demonstrating **systolic flow reversal.** **ASV wave in ASVD wave are merged**
111
What is the Peak velocity with severe TR?
Gradient actually similar between atria Paradoxical
112
What is TR jet vena contracta with severe TR?
**\>7 mm**
113
label these waves
**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
What is the formula for EF?
(EDV - ESV) / EDV
115
What is the formula for stroke volume?
EDV - ESV
116
What is the formula for velocity ratio when doing aortic valve calculations?
AreaAV / AreaLVOT = VelocityLVOT / VelocityAV
117
What is the defintion of aortic sclerosis that does not meet mild AS (normal) on **aortic jet velocity**?
\< 2.5 m/s
118
Aortic Jet Velocity: ## Footnote **Mild AS**
2.6 - 2.9 m/s
119
Aortic Jet Velocity: ## Footnote **Moderate AS**
3 - 4 m/s
120
Aortic Jet Velocity: **Severe** **AS**
\>4 m/s
121
Mean Gradient per American Guidelines ## Footnote **Mild AS**
\<20 mmHg
122
Mean Gradient per American Guidelines ## Footnote **Moderate AS**
20 - 40 mmHg
123
Mean Gradient per American Guidelines ## Footnote **Severe AS**
\>40 mmHg
124
AVA by continuity equation for: ## Footnote **Mild AS**
\>1.5 cm2
125
AVA by continuity equation for: ## Footnote **Moderate AS**
1.0 - 1.5 cm2
126
AVA by continuity equation for: ## Footnote **Severe AS**
\<1.0 cm2
127
Indexed AVA ## Footnote **Mild AS**
\>0.85 cm2/m2
128
Indexed AVA ## Footnote **Moderate AS**
0.6 - 0.85 cm2/m2
129
Indexed AVA ## Footnote **Severe AS**
\<0.6 cm2/m2
130
Velocity Ratio ## Footnote **Mild AS**
\>0.5
131
Velocity Ratio ## Footnote **Moderate AS**
0.25 - 0.5
132
Velocity Ratio ## Footnote **Severe AS**
\< 0.25
133
What can be caculated from **Peak Early Velocity** of the aortic valve?
\*\*Check this answer with an attending\*\*
134
What can be caculated from **Peak Late Velocity** of the aortic valve in aortic insufficiency?
LVEDP
135
Given a BP of 100/55, what is the LVEDP when you have a peak late velocity of 3.38 m/sec?
Change in Pressure = 4V2 = AoDP - LVEDP 4 (VAI LATE) = 4(3.38)2 LVEDP = 55mmHg - 45.7 mmHg **LVEDP = 9.3 mmHg**
136
What is helpful when using the dimensionless index (velocity ratio) for BMI considerations?
**Size independent**
137
What is the difference of LVOT area in 2d (ME AV LAX) vs. 3d?
2D = **Underestimates LVOT** area = **Overestimate the degree of stenosis** **2D = D1** but this is more of an ellipse
138
This card marks questions on the practice exam (No question)
This card marks questions on the practice exam (No answer)
139

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