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Hemodynamics, Formulas, Prosthetics Flashcards

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USMLE® Step 1 flashcards
1
Q

Valve area using PHT:

A

MVA = 220 / PHT

TVA = 190 / PHT

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2
Q

Calculate PHT using deceleration time

A

PHT = 0.29 x DT

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3
Q

What is the formuala for CO?

A

C0 = SV x HR

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4
Q

Calculate SV and CO

  • E wave DT - 910 ms
  • Mean diastolic mitral gradient - 17 mmHg
  • Diastolic mitral inflow - VTI - 66 cm
  • HR - 85 bpm
A
  • SV = CSA (MVA) x VTI
  • MVA = 220/PHT
  • PHT = 0.29 x DT
  • SV = 0.8 cm2 x 66 cm
  • CO = 53 mL x 85 b/min = 4.5 L / min
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5
Q

Define ductus arteriosus (PDA)?

Explain the physiology behind a ductus arteriosus

A
  • extracardiac shunt resulting from a communication between the descending thoracic aorta (DTA) and the proximal left pulmonary artery
  • in utero, the blood that reaches the pulmonary artery from the RV cannot enter the collapsed (partially functional) lungs; instead it is diverted across the ductus arteriosus into the DTA
  • Soon after birth, the pressure in the pulmonary artery falls below the pressure in DTA and blood flow in the ductus arteriosus reverses its direction –> flow from DTA into pulmonary artery
  • High O2 content of the ductal blood triggers closure of the ductus arteriosus in most newborns
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6
Q

What is the major difference in flow calculations in pateints with PDA?

A
  • Flow exiting LVOT (normally Qs) = Qp
  • Flow exiting RVOT (normally Qp) = Qs

*****Most individuals with PDA, Qp > Qs

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7
Q

What is the formula for shunt flow (SF) in the setting of PDA?

A

SF = Qp (LVOT) - Qs (RVOT)

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8
Q

What is a complication of (untreated) PDA?

A
  • Eisenmenger physiology
    • R-to-L shunting of deoxygenated blood
    • cyanotic lower extremities because deoxygenated blood from the PA crosses the PDA and enters the DTA past the origin of the aortic arch vessels, which supply fully oxygenated blood to the head and the arms
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9
Q

Explain the relationship between RAP and RVDP

A

can be considered equal in the absence of TS

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10
Q

What is the formula for pressure gradient between PADP and RVDP?

A
  • PADP - RVDP = 4V2
    • absence of TS, RVDP = RAP
  • PADP - RAP = 4V2
  • PADP = 4V2 + RAP
    • V = Vend diastolic velocity
  • RAP
    • > / < 2.1 cm
    • > / < 50% collapse on sniff test
    • 3, 8, 15 mmHg
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11
Q

What are findings consistent with severe MR?

A
  • Grades 3+ and 4+
  • EROA - > 0.4 cm2
  • RF - > 50%
  • RV - > 60 mL
  • VC - > 0.7 cm
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12
Q

What is the formula for instantaneous flow rate across the mitral valve?

A
  • Calculated using PISA method
  • IFR = 6.28 r2 x aliasing velocity
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13
Q

What is the formula for SV?

A

SV = 0.785 x d2 x LVOTVTI

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14
Q

What is the formula for regurgitant volume (RV)?

A

RV = EROA x VTICW

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15
Q

What is the formula for MVA (using PISA)?

A

MVA = 6.28 x V2 x aliasing velocity / Peak velocityMS x angle correction

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16
Q

What is the formula for LVOT gradient (using MR)?

A

LVOT gradient = 4VMR2 + LAP - SBP

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17
Q

What is Teicholz formula for LV volume / SV?

A

SV = (7 x LVEDD3 / 2.4 x LVEDD) x LVEF

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18
Q

What is the formula for projected AVA?

A

Projected AVA = AVA rest + [(AVApeak - AVArest) / (Qpeak - Qrest)] x (250 - Qrest)

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19
Q

What is the formula to calculate pulmonary artery wedge pressure?

A

PAWP = 4.6 + 5.27 x E / Vp

  • E = mitral inflow peak velocity
  • Vp = flow propagation velocity of the mitral inflow (cm/s) obtained by color M-mode
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20
Q

What does flow propagation velocity of mitral inflow (Vp) measure?

A
  • measures the rate at which red blood cells reach the LV apex from the mitral valve level during early diastole
  • obtained on color M-mode
  • indirect measure of LV relaxation
    • lower the Vp, the slower the LV relaxation and higher the LVDP
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21
Q

Explain the findings of mitral E and A wave in the setting of elevated LAP (or PAWP)

A
  • Peak E wave >> A wave
  • Patients will have one of two patterns:
    • Pseudonormal filling pattern
      • E/A between 1 - 2
      • E wave deceleration time > 160 ms
    • Restrictive filling pattern
      • E/A > 2
      • E wave deceleration time < 160 ms
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22
Q

What will be the mitral E wave to mitral annular tissue Doppler e’ wave (E/e’) be in the setting of elevated LAP and PAWP?

A

> 15

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23
Q

What is a normal Vp (propagation of mitral inflow velocity)?

A
  • Young individuals = > 55 cm/s
  • Middle-aged = > 45 cm/s
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24
Q

What findings are consistent with severe AR?

A
  • Grades 3+ and 4+
  • EROA >0.3 cm2
  • RF > 50%
  • RV > 60 mL
  • VC > 0.6 cm
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25
Q

What measure is directly proportional to left atrial pressure?

A
  • LAP = E/e’
    • mitral E wave (inflow) to mitral annular tissue Doppler e’ wave
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26
Q

What measure is Doppler e’ wave directly proportional to?

A
  • rate of LV relaxation during early diastole
    • slower the LV relaxation –> higher LV diastolic pressure (LVDP)
    • increased LVDP –> increased LAP and PAWP (to allow for better filling of a stiff LV)
    • higher the LAP –> the taller the mitral E wave becomes
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27
Q

Explain what happens in regards to E and e’ as LV diastolic dysfunction worsens

A
  • peak velocity of annular tissue e’ wave gets smaller
  • mitral E wave gets higher
  • E/e’ gets progressively larger –> reflecting the rising LAP and PAWP
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28
Q

Describe the medial E/e’ severity scale

A
  • Normal < 8
  • Indeterminate 8 - 15
  • Elevated > 15
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29
Q

Describe the lateral E/e’ severity scale

A
  • Indeterminate 8-12
  • Elevated > 12
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30
Q

What is the equation to estimate LAP?

A

LAP = 1.9 + 1.24 x E/e’

Simplified: LAP = 4 + E/e’

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31
Q

What is the formula to calculate LVSP (in presence of MR)?

A

LVSP = 4VMR2 + LAP

  • VMR = peak systolic gradient of the MR jet
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32
Q

What is the formula to calculate peak-to-peak gradient of AS?

A

P2P = LVSP - SBP

****P2P gradient is not a physiologic one because it represents a pressure difference at separate points in time

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33
Q

What is normal dP/dt?

A

dP/dt = 1661 + 323

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34
Q

What is the formula to calculated LVEDP using DBP?

A
  • DBP - LVEDP = 4V2
  • LVEDP = DBP - 4Vend diastolic velocity2
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35
Q

What PHT indicates severe AR?

A

PHT < 300 ms

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36
Q

What is the relationship between LVSP and SBP in patients with AS?

A

peak LVSP is always higher than peak SBP

  • LVSP becomes progressively higher as AS becomes more severe
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37
Q

Can the continuity equation be used in the evaluation of AS in the presence of significant AR?

A

Yes

  • increased flow will proportionally effect VTI of both LVOT and AV
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38
Q

What is one factor that can preclude an ASD closure?

A

Increased PVR

  • not pulmonary hypertension alone
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39
Q

What is the formula to calculate RVSP and PASP from VSD?

What information must be known?

What cannot be present?

A
  • RVSP = SBP - Vpeak systolic VSD gradient
  • RVSP = SBP - 4V2
  • SBP must be known
  • no LVOT obstruction can be present
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40
Q

What is the formula to calculate PASP if RVSP is known?

A
  • PASP = RVSP
    • if no PS is present
  • PASP = RVSP - Peak PS gradient
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41
Q

What is the formula to calculate RVEDP in the setting of VSD?

What must be provided?

A
  • RVEDP = LVEDP - Vend-diastolic gradient
    • ​RVEDP = LVEDP - 4V2
  • LVEDP must be provided
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42
Q

How do you calculate RVOT SV in the setting of an ASD (L-to-R shunt)?

A

SVRVOT = SVLVOT + SVASD

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43
Q

What is the formula to calculate Qp (in setting of ASD)?

A

Qp = Qs + ASDshunt flow

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44
Q

Describe dP/dt

A
  • a measure of left ventricle systolic function
  • dP - rate of pressure rise in the left ventricle
  • dt - time
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45
Q

What is the formula used to calculate dP/dt?

A
  • dP/dt = ΔP / RTI
    • RTI = relative time interval (measured in seconds) between MR jet velocities
    • change in pressure (ΔP) - represents the pressure difference between the left ventricular to LAP gradients at V2 and V1
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46
Q

Calculate dP/dt

A
  • dP/dt = ΔP / RTI
  • ΔP = 4V22 - 4V12
  • ΔP = 36 - 4 = 32 mmHg
  • RTI = Time at V2 - Time at V1 = 25 - 5 = 20 ms –> 0.02s
  • dP/dt = 32mmHg / 0.02s –> 1,600 mmHg/s
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47
Q

What is the expected peak E velocity when severe (native) MR is present?

A

> 1.5 m/s

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48
Q

What is the expected peak E velocity when severe (prosthetic) MR is present?

A

> 2.0 m/s

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49
Q

Calculate LAP

A
  • LVSP = ΔP + LAP
  • LAP = LVSP - ΔP
    • SBP can be substituted for LVSP in the absence of LVOTO or AS
  • LAP = 95 mmHg - 4(4)2
  • LAP = 95 mmHg - 64 mmHg
  • LAP = 31 mmHg
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50
Q

What is normal dP/dt?

A

1661 + 323 mmHg/s

  • 900 mmHg/s –> indicates markedly diminished LV systolic function as seen in cardiogenic shock
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51
Q

What are findings consistent with very severe MS?

A
  • MVA < 1.0 cm2
  • PHT > 200 ms
  • MG > 10 mmHg
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52
Q

What findings are consistent with severe MS?

A
  • MVA 1.0 - 1.5 cm2
  • PHT 150-220 ms
  • MG 5-10 mmHg
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53
Q

What findings are consistent with Progressive MS?

A
  • MVA > 1.5 cm2
  • PHT < 150 ms
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54
Q

Calculate LAP

A
  • LAP = MG in diastole + Early LV diastolic pressure
  • LAP = 21 mmHg + 7 mmHg = 28 mmHg
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55
Q

What is the relationship between velocity and area of an orifice?

A

inversely related

  • V = 1 / CSA (or MVA in setting of MS)
    • smaller or more severe the stenosis, the higher the velocity (E wave velocity)
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56
Q

Why is PHT (assessment of MS) not reliable after PMBV?

A
  • PHT method assumes LV pressure and compliance are normal
  • PMBV –> sudden increase in mitral orifice area leading to an increase in the SV delivered to the LV in early diastole
  • Because LV compliance cannot acutely change, the LVDP increases
  • Increase in LVDP –> diastolic gradient between the LA and LV decreases and the mitral PHT shortens (above and beyond what would be expected by an increase in the MVA alone after valvuloplasty)
  • PHT method –> erroneously large MVA
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57
Q

What are two ways to utilize diminsionless index (in assessment of AS)?

A

VTILVOT / VTIAV

or

PVLVOT / PVAV

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58
Q

Calculate AVA

A
  • AVA = CSALVOT x VTILVOT / VTIAV
  • AVA = CSALVOT x DI
    • DI can be calculated using VTI or PV
  • AVA = 0.785 (1.9)2 x (1 m/s) / (5 m/s)
  • AVA = 2.84 cm2 x 0.2
  • AVA = 0.6 cm2
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59
Q

Calculate SV

A
  • SV = CSALVOT x VTILVOT
  • SV = 0.785 (1.9)2 x 20 cm
  • SV = 57 mL/beat
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60
Q

How can you calculate the MG from peak velocity (in assessment of AS)?

A
  • ΔPVmax = 4VAV2
    • V = peak velocity across AV
  • MG is approximately 60% of the PG (ΔPVmax)
    • ΔPmean = 0.6 x ΔPVmax
61
Q

Describe the findings

A
  • Severe PI
    • common long-term complication of ToF repair
    • large regurgitant orifice, the pressure gradient between the pulmonary artery and the RV equalizes rapidly –> premature cessation of the pulmonic regurgitant jet
    • equalization is achieved by mid diastole and there is no measureable end-diastolic gradient demonstrated
62
Q

Describe the findings of end-diastolic gradient and RVSP in the setting of severe PI

A
  • Very low, approaching zero
  • RVSP exceeds PASP by 9 mmHg
63
Q

Calculate LAP

A
  • Mean LAP can be estimated semiquantitatively from peak flow velocity of mitral E wave (E) and peak velocity of mitral annular tissue Doppler wave (e’)
  • E/e’ = 142 / 8 = 18 –> elevated LAP
64
Q

Describe the mitral inflow and LV relaxation pattern

A
  • Restrictive filling pattern
  • Mitral inflow pattern is a combination:
    • abnormal LV relaxation –> E/A wave > 2
    • elevated LAP –> rapid E wave deceleration time ( < 160 ms)
65
Q

Explain the effects of mitral inflow velocity (E) with Valsalva maneuver

A
  • PV of the mitral E wave is expected to decrease
    • Valsalva –> decrease preload
    • lower early diastolic pressure gradient between LA and LV –>
    • lower peak velocity of the mitral E wave and a lower mitral E/A ratio
66
Q

Describe what causes:

  • mitral inflow A wave
  • atrial reversal (AR) wave
A
  • In sinus rhythm, the LA contracts following the P wave on EKG and the blood is propelled both forward into the LV across the MV, as well as backward into the pulmonary veins, which lack valves
    • mitral inflow (A) wave: forward flow
    • atrial reversal (AR) wave: retrograde flow into the pulmonary veins
67
Q

Describe the effects on AR wave in the setting of elevated LVDP (at the time of atrial contraction)

A

Both peak velocity and duration of the AR wave are increased

68
Q

What peak AR velocity is indicative of elevated LVDP?

A

> 35 cm/s

69
Q

What AR duration inferrs elevated LVDP?

A

> 30 ms more than mitral inflow (A) wave duration

  • PV AR wave - PV mitral inflow A wave
    • 201 ms - 170 ms = 40 ms
70
Q

Explain the effects of A-fib on AR wave

A

AR wave is absent in atrial arrhythmias

71
Q

What is the effect of LAP on S (systolic) and D (diastolic) waves in pulmonary vein tracings?

A

higher the LAP –> lower S/D ratio

72
Q

Explain the effects of constrictive pericarditis

A
  • Ventricular filling is constrained by an inelastic pericardial sac that envelopes the entire heart except for the cranial portion of the left atrium and pulmonary veins. This leads to:
    • ventricular interdependence
    • differential impact of negative intrathoracic pressure that develops during inspiration on pulmonary veins and the heart
73
Q

Define ventricular interdependence

When does this occur?

A
  • diastolic filling of one ventricle at the expense of the other depending on the respiratory phase
    • Net effect of inspiration –> RV fills at the expense of the LV (interventricular septum moves toward the LV)
      • opposite occurs in expiration
  • Constrictive pericarditis
    • Inspiration
      • pressure in the intrathoracic systemic vein decreases
      • leads to a larger pressure gradient between extra- and intrathoracic systemic veins –> results in improved RV filling
      • At the same time, the drop in intrathoracic pressure with inspiration decreases the pulmonary venous pressure
      • Because of the thickened rigid pericardium, the drop in the intrathoracic pressure cannot be transmitted to the heart; this results in a decreased pressure gradient between pulmonary veins and the left atrium, and decreased LV filling in diastole
74
Q

Describe the findings

A
  • Constrictive pericarditis
    • M-mode: ventricular interdependence
      • inspiration –> RV fills at expense of LV –> interventricular septum moves toward the LV (opposite occurs in expiration)
      • Hepatic vein doppler: exaggerated flow in inspiration/expiration due to shifting of the interventricular septum
        • Inspiration –> exaggerated forward flow
        • Expiration –> exaggerated flow reversal
75
Q

Describe the findings

A

Coarctation of the aorta (severe)

  • holodiastolic / antegrade flow throughout the cardiac cycle
  • large peak systolic gradient ~ 60 mmHg
76
Q

Explain the difference in the spectral doppler tracings

A
  • Normal systole consists of:
    • isovolumic contraction time
    • ejection period
  • A - Tricuspid regurgitant jet
    • extends throughout systole
  • B - Aortic stenosis jet
    • shorter duration
    • later onset (compared to TR jet)
77
Q

Describe the findings

A
  • Cardiac tamponade
    • Mitral inflow –> abnormal relaxation
      • peak velocity of the mitral E wave is lower than that of the A wave
      • deceleration time is prolonged
    • Inspiratory drop (respiratory variation) in mitral inflow E wave > 25%
      • ​ΔE = Eexpiration - Einspiration / Eexpiration
      • ΔE = 170 - 110 / 170 = 60 / 170 = 35%
78
Q

What are two major findings on spectral Doppler indicative of constrictive pericarditis and cardiac tamponade?

A
  • Diastolic dysfunction
    • CP –> restrictive filling pattern (E/A > 2, E wave DT < 160 ms)
    • CT –> abnormal relaxation pattern (E/A > 1)
  • Inspiratory drop (respiratory variation) in mitral inflow E wave > 25%
79
Q

What is one finding that is consistent in both constrictive pericarditis and pericardial tamponade?

A

Ventricular interdependence

or

Inspiratory drop (respiratory variation) in mitral inflow E wave > 25%

80
Q

When are respiratory variations measured in cardiac tamponande and constrictive pericarditis?

A

peak velocity of the E wave

81
Q

What can differentiate findings of constrictive pericarditis and cardiac tamponade on spectral Doppler tracings?

A
  • Mitral inflow filling pattern / diastolic dysfunction
    • CT = E/A > 2
    • CP = E/A > 1
82
Q

Describe the findings

A
  • Severe TR (RAP rises progressively toward the end of ventricular systole)
    • A - when tricuspid regurgitant orifice is large, there is ventricularization of the RAPs –> very rapid pressure equilibration between RVP and the RAP
    • B - Rapid rise in RAP –> rapid deceleration slope of the tricuspid regurgitant jet (blue arrow)
    • C - Systolic wave reversal in hepatic vein spectral doppler tracings in a patient with severe TR
83
Q

Why is RV function normal in this spectral Doppler tracing?

A
  • Normal RV function
    • Acceleration rate in tricuspid regurgitant jet velocities from baseline to peak velocity is fast
    • Indicative of a normal dP/dt and a normal RV function
84
Q

Describe details of severe TR on spectral Doppler wave

A
  • low peak velocity
  • rapid deceleration slope due to rapid pressure equilibration between RV and RA
85
Q

Describe findings consistent with normal mitral annular tissue Doppler recordings?

A
  • Peak velocity of the early diastolic (E’) wave of at least 10 cm/s at either medial or lateral mitral annulus
  • Peak E’ veolicty is normally higher in the lateral compared to the medial annulus
    • E’ lateral / E’ medial > 1
  • E’ velocity is typically higher than the peak velocity of the late diastolic (A’) wave
86
Q

Describe the findings and diagnosis

A
  • Annulus reversus - Constrictive pericarditis
    • ​overall peak E’ velocities within normal range but
    • medial E’ velocity is much higher than the lateral E’ velocity
      • lateral E’ / medial E’ = < 1 (Annulus reversus)
    • lateral E’ velocity diminishes relative to medial E’ due to fibrosis and calcifications in the pericardium which restrict annular motion
87
Q

What are the mitral annular tissue doppler findings in a patient with MR secondary to flail leaflet?

A

lateral E’ velocities higher than medial E’ velocities

88
Q
  • Caclulate LAP
    • RAP = 8 mmHg
A
  • LAP = Peak ASD gradient + RAP
  • LAP = 4 (3.3)2 + 8
  • LAP = 44 + 8 = 52 mmHg
89
Q

Describe the findings and diagnosis

A
  • Mitral regurgitation (moderate) secondary to mitral valve prolapse
    • MVP causes discordance between the EROA and RV due to its peak in late systole
90
Q

When is MR not holosystolic?

A

MVP (late systolic)

91
Q

What are the best measures of MR severity in MVP?

A
  • RV and RF
    • EROA overestimates severity due to the late systolic regurgitant jet
92
Q

What is the formula for regurgitant fraction?

A

Regurgitant fraction = RV / (RV + SVforward)

93
Q

Describe the findings in moderate MR?

A
  • Grade 2+
  • EROA 0.2-0.29 cm2
  • RF 30-39%
  • RV 30-44 mL
  • VC 0.3-0.7 cm
94
Q

Describe the findings in moderate-severe MR?

A
  • Grade 3+
  • EROA 0.3-0.39 cm2
  • RF 40-49%
  • RV 45-59 mL
  • VC 0.3-0.7 cm
95
Q

Describe the findings in mild MR?

A
  • Grade 1+
  • EROA < 0.2 cm2
  • RF < 30%
  • RV < 30 mL
  • VC < 0.3 cm
96
Q

Describe the findings

A

Abnormal relaxation pattern (grade I diastolic dysfunction)

97
Q

Describe the findings

A

Pseudonormal pattern (grade II diastolic dysfunction)

98
Q

Describe the findings

A

Restrictive filling pattern (grade III diastolic dysfunction)

*** acute decompensated heart failure due to ACS (STEMI) in distribution of LAD

99
Q

Describe the findings

A
  • Mitral inflow in a patient with mechanical mitral valve
    • note the vertical line artifact due to opening and closing of the prosthetic leaflets
100
Q

Describe the findings

A

Mitral inflow in a patient with A-fib

101
Q

What are the hemodynamic formulas for LAP?

A
  • LAP = 4 + E/e’
  • LAP = 1.9 + 1.24 x E/e’
  • LAP = SBP - 4 (MRVmax)2
  • LAP = LVSP - 4 (MRpeak systolic velocity)2
  • LAP = RAP + 4(ASDpeak systolic velocity)2
102
Q

Which papillary muscle ruptures more commonly post-MI?

A

Posteromedial papillary muscle

  • has only single blood vessel supply (from RCA or CFx)

****Anterolateral papillary muscle –> blood supply from both the LAD and CFx

103
Q

Describe how to calculate Pulmonary artery systolic and diastolic BP in the setting of PDA?

  • SBP 170/70
  • HR 72 bpm
  • RAP 10 mmHg
A
  • PSG = 4 (PSV)2
    • PSG = 4 (6)2 = 144 mmHg
  • EDG = 4 (EDV)2
    • 4 (3.8)2 = 58 mmHg
  • Pulmonary artery SBP can be callculated by subtracting PSG and EDG from SBP and DBP
    • PASP = SBP - PSG
      • 170 - 144 = 26 mmHg
    • PADP = DBP - EDG
      • 70 - 58 = 12 mmHg
  • Pulmonary artery SBP = 26 / 12 mmHg
104
Q

What are the hemodynamic formulas for PASP/RVSP?

A

PASP = RVSP (if no PS present)​

  • RVSP
    • RVSP = 4 (TRVmax)2 + RAP
    • RVSP = SBP - 4(VSDVmax)2
    • RVSP = PASP + PSgradient​
  • RVEDP = LVEDP - 4(VSDdiastolicy velocity)2
  • PAEDP = 4 (PRend diastolic velocity)2 + RAP
105
Q

What are the hemodynamic formulas for mPAP (mean pulmonary artery pressure)?

A
  • mPAP = 2/3 PADP + 1/3 PASP
  • mPAP = 4 (PRpeak velocity)2 + RAP
  • mPAP = Mean ΔP(RV-RA) + RAP
  • mPAP = 79 - (0.45 x RVOT AcT)
106
Q

What are the hemodynamic formulas for PVR?

A
  • PVR = 10 (TRpeak systolic velocity) / RVOT VTI) + 0.16
  • PVR = mPAP - mPCWP / CO
107
Q

What are the hemodynamic formulas for LVSP?

A
  • LVSP = 4 (MRpeak systolic velocity)2 + LAP
  • LVEDP = DBP - 4 (ARend diastolic velocity)2
108
Q

What three measures can be used to obtain peak LVOT gradient (in HOCM)?

A
  • PGMR jet - PV = 8 m/s
  • LAP - 10 mmHg
  • SBP - 144 mmHg

Steps:

  • PMR = 4 (8)2 = 256 mmHg
  • LVSP = ΔPMR + LAP
  • LVSP - 256 mmHg + 10 mmHg = 266 mmHg
  • ΔPLVOT = LVSP - SBP
    • ΔPLVOT = 266 - 144 = 122 mmHg
109
Q

Describe the findings and diagnosis?

A

MR in HOCM

110
Q

Describe the findings and diagnosis

A

Typical MR Jet

111
Q

Describe the findings and diagnosis

A

Diastolic MR

112
Q

Describe the findings and diagnosis

A
113
Q

Describe the findings and diagnosis

A

Pulsed wave spectral doppler tracing of a LV intracavitary gradient

114
Q

Describe the findings and diagnosis

A

HOCM with SAM/MR

  • Jet #1 –> MR flow velocity pattern
  • Jet #2 –> HOCM with systolic flow velocity pattern across the LVOT
115
Q

What is the formulat for the area-length method for calculating LA volume

A

LAV = 0.85 x (A1 x A2 / L)

  • A1 = left atrial area in A4C view
  • A2 = left atrial area in A2C view
  • L = shorter of two atrial lengths
116
Q

Describe severity scale of LAVI?

A
  • Normal < 34 mL/m2
  • Mild dilatation 35 - 41 mL/m2
  • Moderate dilatation 42-48 mL/m2
  • Severe dilatation > 48 mL/m2
117
Q

This is inversely related to peak of the systolic (S) wave on pulmonary venous spectral Doppler tracings?

A

Left Atrial Pressure

118
Q

Describe the findings

A

Abnormal relaxation

119
Q

Describe the findings

A

Pseudonormalization

120
Q

Describe the findings

A

Restrictive filling

121
Q

Describe the findings in CHF patient who has been treated x 5 days (follow up Echo)

A
  • Initial (acute decompensated heart failure)
    • Restrictive filling pattern
      • high left atrial pressure –> tall mitral E wave
      • E/A > 2
      • Rapid E wave DT < 160 ms
    • Pulmonary venous doppler tracing
      • S < D = elevated LAP and restrictive filling pattern
  • Follow up (s/p 5 days of treatment)
    • Decreased LAP
    • Abnormal relaxation
      • E < A pattern (in mitral inflow)
      • Prolonged DT
    • Pulmonary venous doppler tracing
      • S > D = lower LAP
122
Q

What information is required to differentiate normal and pseudonormal pattern of diastlic dysfunction?

A
  • Mitral annular tissue Doppler e’
    • Normal = e’ > 8 cm /s
    • Pseudonormal = e’ < 8 cm/s
123
Q

Define Patient Prosthesis Mismatch (PPM)

A
  • the situation in which effective orifice area (EOA) of a prosthesis is too small relative to the patients body size
  • resulting in abnormally high postoperative gradients
124
Q

What is the EOA (indexed) cutoff in regards to PPM for a prosthesis in the aortic position?

A

EOA indexed ≤ 0.85 cm2 / m2

  • smaller areas –> rapid increase in transvalvular gradients
125
Q

What is the EOA (indexed) cutoff for severe PPM for a prosthesis in the aortic position?

A

EOA indexed ≤ 0.65 cm2 / m2

126
Q

What are the major adverse outcomes associated with PPM?

A

short-term and long-term survival

particularly if associated with LV dysfunction

127
Q

What peak velocity should prompt further evaluation in assessment of aortic prosthetic valves?

A

> 3 m/s

128
Q

What is the severity scale for aortic prosthetic valves?

  • Peak velocity
A
  • Normal < 3 m/s
  • Possible stenosis 3-4 m/s
  • Significant stenosis > 4 m/s
129
Q

Describe the algorithm in evaluating aortic prosthesis with PV > 3 m/s

A
130
Q

Assessment of peak and mean gradients across the mitral/tricuspid valve prostheses are greatly dependent upon this?

A

Heart rate

  • gradients across mitral and tricuspid prostheses are very HR dependent
131
Q

What is the severity scale for mitral prosthetic valves?

  • Peak velocity
A
  • Normal < 1.9 m/s
  • Possible stenosis 1.9-2.5 m/s
  • Significant stenosis > 2.5 m/s
132
Q

What is the severity scale for mitral prosthetic valves?

  • Mean gradient
A
  • Normal ≤ 5 mmHg
  • Possible stenosis 6-10 mmHg
  • Significant stenosis > 10 mmHg
133
Q

What is the severity scale for aortic prosthetic valves?

  • Mean gradient
A
  • Normal < 20 mmHg
  • Possible stenosis 20-35 mmHg
  • Significant stenosis > 35 mmHg
134
Q

What is the severity scale for aortic prosthetic valves?

  • DVI
A
  • Normal ≥ 0.30
  • Possible stenosis 0.29 - 0.25
  • Significant stensosi ≤ 0.25
135
Q

What is the severity scale for mitral prosthetic valves?

  • VTIPrMV / VTILVOT
A
  • Normal < 2.2
  • Possible stenosis 2.2 - 2.5
  • Significant stenosis > 2.5
136
Q

What is the severity scale for mitral prosthetic valves?

  • EOA
A
  • Normal ≥ 2cm2
  • Possible stenosis 1-2 cm2
  • Significant stenosis < 1 cm2
137
Q

What is the severity scale for aortic prosthetic valves?

  • EOA
A
  • Normal > 1.2 cm2
  • Possible stenosis 1.2 - 0.8 cm2
  • Significant stenosis < 0.8 cm2
138
Q

What is the severity scale for mitral prosthetic valves?

  • PHT
A
  • Normal < 130 ms
  • Possible stenosis 130 - 200 ms
  • Significant stenosis > 200 ms
139
Q

What is the severity scale for aortic prosthetic valves?

  • Acceleration time (AT)
A
  • Normal < 80 ms
  • Possible stenosis 80 - 100 ms
  • Significant stenosis > 100 ms
140
Q

What are findings suggestive of prosthetic TS?

A
  • PV ≥ 1.7 m/s
  • MG ≥ 6 mmHg
  • PHT ≥ 230 ms
141
Q

What is the severity scale for aortic prosthetic valves?

  • jet velocity contour
A
  • Normal - triangular, early peaking
  • Possible stenosis - triangular to indeterminate
  • Significant stenosis - rounded, symmetrical contour
142
Q

What do microcavitations (in harmonic imaging) indicate in prosthetic valve assessment?

A

normal prosthetic valve

143
Q

What prosthetic valves demonstrate the greatest degree of pressure recovery?

A

Bileaflet (small)

and

Ball and cage

144
Q

What are the recommendations in regards to PHT in assessment of prosthetic valves?

A

Should not be used / Inaccurate

145
Q

In which mitral valve prosthesis is a large central jet most consistent with normal valve function?

A

Medtronic-Hall single disc valve

146
Q

In which mitral valve prosthesis is the largest degree of physiologic regurgitation seen?

A

Bileaflet valves

  • central and peripheral jets
147
Q

What is recommended whenever paravalvular regurgitation is suspected?

A

TEE

  • essential to the evaluation of paravavular regurgitation
148
Q

What are four criteria used to identify constrictive pericarditis?

A
  • Ventricular inderdependence (septal motion abnormality)
  • Mitral inflow velocity ≥ Grade 2
  • Mitral annulus medial e’ ≥ 8 cm/s
  • Hepatic vein diastolic expiratory flow reversal
149
Q

What are mimickers of constriction?

A
  • Restrictive cardiomyopathy
  • Severe TR
  • Ventricular interdependence (other causes)

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