Hemodynamics Flashcards
Effective oriface area: severe
MR v AR
MR 0.4 cm2 vs AR 0.3 cm2
Both 60 cc/beat
Diastole longer than systole, so AR lasts longer than MR
Regurgitant volume
Difference in RV stroke volume - LV stroke volume
AS DVI
Lvot vti/ Ao vti
< 25 severe
PISA eroa
2 pie r2 x vel of alias velocity/ vel of regurg
Mild < 20cm2, severe > 40 cm2
Rv is ero x vto
Technical difficulties with est LV filling- tachy
Pr fused e/a
L wave
E L A
Suggests stiff LV
Ski slope PI
Indicates elevated PA pressure
Short DT
Increased volume load,decreased compliance
Annulular velocity constriction
L>s except constriction s> l
Annulus inversion
MV tilt direction
Major oriface to free wall (posterior) to decrease turbulence
DVI
Nl > 0.3
Indeterm 0.29-0.25
Severe < 0.25
Acceleration time AT aov
> 100 msec stenotic
Prosthetic valve mismatch
Nl > 0.85
Severe ieoa< 0.65
p1/2 MV
Decl time P1/2= DT x 0.29
MVA = 220/pht
Tricuspid stenosis
> 5 mmhg
Discrete sub aortic stenosis
M mode flutter
Av closure premature
Pressure recovery
Aortic
Mod as with small asd Ao
Ao < 3.0
Acute severe AI affect MV
Diastolic MR
Premature closure MV
Aorta marfan’s
5.0 cm
Aortic insuff vena contracts
Mild < 0.3 cm, severe > 0.6 cm
AS < 70, > 70
< 70 bicuspid
> 70 degenerative
2D MR jet
< 20% mild
20-40 mod
> 40% severe
MR vena contracta
< 0.3 mild
> 0.7 severe
Mitral reg volume
MV stroke volume- lvot stroke volume
MR Rv, rf, ero
Rv < 30% mild, > 60 % severe
Rf 30 mild, 50% severe
Ero .2 mild, > 4 severe
MV p1/2
220/ mva
750/DT
Mitral inflow measurement
Leaflet tips
TAPSE
Tricuspid annular plane excursion
Nl > 1.6
Dil cardiomyopathy < 1.0 mortal 45%/yr
Peak to peak vs instantaneous gradient
70% max instantaneous gradient
LA pressure
= E/e’ + 4
Inaccurate with Mac,ms,prosthetic MV, mr, depressed ef
TDI settings
Wall filter off
Gain down
Spectral vs color tdi
Color lower velocities
S1component
First pul vein wave related to LA relaxation (absent in afib)
S2: affected by Rv
Left atrial pressure- S2 primary effects as does LV shortening, and mitral annular descent
LV stiffens,what happens to MV inflow velocity
Decel time shortens
E velocity height depends on la pressure- affected later
Findings suggesting vol overload - Doppler/ MV
High transmitral E, short decel
Low s/d ratio
High E/e ratio
Pisa radius severity
Mild if < 0.4
Severe if > 1.0
AR mild / severe
MR mild/ severe
Rv 60 cc severe
Annulus inversion
Constriction limits lateral annulus making it paradoxically less than medial annular velocities
Dobut low output AS
SV/EF/AVA/ mean grad
0-20 mcg dobut stress
Severe if: vel >= 4 m/sec or Ava < 1.0 with > 20% increase in SV
If SV or EF fail to increase by 20% then lack of contractile reserve
Pulmonary vascular resistance
PVR (woods units)= 10 x (vel TR jet/ VTI rvot)
Septal flattening
Elevated RV pressure- flatten systole and diastole
Volume flatten most in diastole
TR vena contracta
> 7 mm severe TR
Hepatic flow reversal
If not in sinus may have even when regurg not severe
Doppler signal: obstructive CM v mitral regurg?
Velocity always higher in MR than HCM
Pulsus paradoxus
Decline of sbp > 20 mmhg with inspiration
Pericardial reflection
Oblique sinus ( pul vein orifaces) Transverse sinus ( great vessels
AVA
AVA= cross sectl area of lvot ( 3.14x r squ) x VTI of lvot / VTI as jet
Simplified
AVA = CSA lvot x V lvot / V max
Sig AI when calc AS
Vena contracta > 3mm
Dimensionless ratio
Outflow tract: aortic jet vel
Normal 1.0
Mild 0.5
Severe 0.25
Continuity MVA
SV (transmittal) / VTI of ms jet
SV determined in lvot or across pul valve
Not accurate if sig MR
Rheumatic dz
Mv first then 35% aov
6 % tricuspid valves
Pulm stenosis gradients
Mild < 25 mmhg peak
Moderate 25-50 mmhg
Severe > 50 mmhg peak
Afib and measuring tricuspid or mitral stenosis
Average mean gradient ( more representive of degree of stenosis than peak
PISA alias velocity
Set to 30-40cm/sec
Regurgitant volume
Total vol across valve- SV across competent valve
SV= CSA x VTI = 3.14 x dia/2 sq x VTI
ROA
Regurg SV ( cm3) / VTI of regurg jet ( cm)
Vena contracta severity
AI
MR
AI < 0.3 CM mild , > 0.6 severe
ME < 0.3 mild, > 0.7 severe
ROA MR short cut
Alias vel 40cm/sec
Assume MR vel 5 m/ sec
Roa is r sq / 2
Root replace size bicuspid aov
> 5.0 CM Ao root
> 4.5 if avr done
MV anatomy:
2d with aortic valve in view
p1 or p2
Commisural view, MV
p1 lateral, a2, p3
If move right p2 or a2
Constriction and restriction share what hemodynamic measurement
E short decel time
IVRT short
MR vena contracta
< 0.3 mild
> 0.7 severe
MR regurg volume calculation:
Mitral annular VTI x CSA mitral annulus- LVOT stroke volume
MR :
Regurg volume
Regurg fraction
ERO
60cc
rF < 30, > 50 %
< 0.2, > 0.4
Eoa in prosthetic MV Mean 6.1 mmhg MV vti 43.4 Pht40 msec SV lovt 64 cc
Cannot due p1/2 ( May use serial studies)
Use continuity with SV/ prmv vti
64 cc/ 31.5= 1.94 cm2
PPM eoa
> 0.85 cm2/ m2 insignificant
Obese pt bmi> 30 may not have effects ppm
Ppm aortic valve parameters
Peak gradient
Dvi
Accel time
Nl < 3.0 m/ sec peak, mean < 20 mmhg,dvi >0.30. Eoa > 2.1 cm2, accel time < 80 msec
DT
Pht= 0.29 DT
EOA prosthetic MV
Do not use dec time or p1/2 due to la compliance and high la pressure
Use SV lvot / MV vti
Loeys-dietz dz
Auto dominant - sim to marfan’s
Transaortic CW velocity 4 m/sec and lovt pw 1.5 m/sec
What is transvalvular gradient ?
P= 4 ( V2-V1)
55 mmhg
P1/2 affected by asd
Will shorten p1/2 and overestimate mva
Deceleration time: grades of diastolic dysfunction
Normal: DT > 160 msec Grade 1: > 200 msec Grade 2: 160-200 msec ( pseudo normal) Grade 3: < 160 msec ( reversible restrictive) Grade 4: < 160 msec. ( fixed restricted)
Pul vein diastolic dysfunction
Normal S>D, AR duration < a duration
Grade 1: S>d, AR dur < a dur
Grade 2: s a dur + 30msec
Vena contracta
MR
AR
Severe > 0.7 CM MR, Pisa radius > 1, RV > 60cc, roa > 0.4
Mild < 0.3cm, Pisa radius < 30cc
Severe AR: > 0.6cm mild 0.3, Rv < 30 mild, severe > 60
S wave
Pul vein: s1 atrial relaxation due to la pressure, contraction, relaxation
S2 from mitral descent due to stroke volume and pulm arterial tree pulse wave propagation
D
A - mitral a <25msec
Definition of AS in dobutamine stress echo
Ava < 1.0 CM 2
With increase in SV > 20%
Or
AV vel > 4.0 CM/sec at any flow rate
Late systolic velocity
Think MVP with regurg
Fusion of pul vein S and D waves
Occurs with pul vein escape route- ie ASD
