Hypertensive heart disease

Question 1

Normal pulmonary artery pressure (PAP) is approximately …..mmHg during systole and ….mmHg at end diastole with a mean PA pressure of about ……..mmHg

Answer 1

Normal pulmonary artery pressure (PAP) is approximately 20-25 mmHg during systole and 6-10 mmHg at end diastole with a mean PA pressure of about 12-16 mmHg

Question 2

Pulmonary hypertension (PH) is defined as systolic pulmonary artery pressure (PAP) above….. and a mean PAP greater than……

Answer 2

> 25-30 mmHg and a mean PAP greater than 20 mmHg.

Question 3

Pulmonar hypertension may be a primary die seas in which no identifiable etiology is present, but more often, it is a secondary disease.

Answer 3

Pulmonar hypertension may be a primary die seas in which no identifiable etiology is present, but more often, it is a secondary disease.

Question 4

Causes of secondary pulmonary arterial hypertension include?

Answer 4

• Left heart failure
• Thromboembolic disease
• Chronic respiratory disease
• Remodeling in response to L-R shunting cardiac defects.

Question 5

The term cor pulmonale traditionally is reserved for pulmonary hypertension related to………and excludes all ……….as an underlying cause.

Answer 5

The term cor pulmonale traditionally is reserved for pulmonary hypertension related to pulmonary hypertension and excludes all left heart disease as as an underlying cause.

Question 6

Determining the presence of pulmonary hypertension should be based on a combination of 2D, M-mode, and Doppler findings.

Answer 6

Determining the presence of pulmonary hypertension should be a combination of 2D, M-mode, and Doppler findings.

Question 7

2D and M-mode findings:
Mild to moderate pulmonary arterial hypertension may show no 2D abnormalities, and spectral Doppler is necessary to document its presence.

Answer 7

Mild to moderate pulmonary arterial hypertension may show no 2D abnormalities, and spectral Doppler is necessary to document its presence.

Question 8

Moderate to severe pulmonary hypertension shows some classic 2D and M-mode changes including?

Answer 8

• RV hypertrophy and dilation, pulmonary artery dilation,
• Septal flattening with paradoxical motion,
• Prolapse of the pulmonary and tricuspid valves,
• Small apparently hypertrophied LV chamber size.

Question 9

Flattening of the interventricular septum changes the LV chamber from a circular shape to a ………. or ……-shaped chamber on transverse views and pushes the interventricular septum down toward the LV chamber on long-axis views.

Answer 9

Flattening of the interventricular septum changes the LV chamber from a circular shape to a triangular or D-shaped chamber on transverse views and pushes the interventricular septum down toward the LV chamber on long-axis views. Fig 6.1

Question 10

As the ratio of L-R ventricular chamber size in dogs with pulmonary hypertension becomes less than……, some degree of PSM is present, and this motion will progressively increase as the right ventricular volume overload increases.

Answer 10

As the ratio of L-R ventricular chamber size in dogs with pulmonary hypertension becomes less than 1,5, some degree of PSM is present, and this motion will progressively increase as the right ventricular volume overload increases.
Fig 6.2, 6.3

Question 11

The PSM is created when?

Answer 11

When right-sided diastolic pressure exceeds left-sided diastolic pressure. This causes the septum to bulge downward during diastole and then correct itself with an exaggerated upward or rightward motion during systole.

Question 12

Differentiating abnormal septal motion secondary to pressure versus volume overload is dependent upon…..?

Answer 12

Upon the timing of the abnormal motion.

Question 13

With volume overload of the right ventricle, diastolic pressure equals or exceeds LV diastolic pressure, but systolic pressure is still much lower than LV systolic pressure. Paradoxical septal motion then occurs during …………., but the septum returns to its normal position during ………….

Answer 13

With volume overload of the right ventricle, diastolic pressure equals or exceeds LV diastolic pressure, but systolic pressure is still much lower than LV systolic pressure. Paradoxical septal motion then occurs during diastole, but the septum returns to its normal position during systole. Fig 6.4

Question 14

When the right ventricle has a pressure overload secondary to pulmonary hypertension, right ventricular systole lasts longer than LV systole causing downward motion of the septum early in ………….. If RV diastolic pressure is also elevated, as is the case in chronic pulmonary hypertension, the elevated pressure is present throughout …………….., and the septum is persistently deformed and flattened. Fig 6.5

Answer 14

When the right ventricle has a pressure overload secondary to pulmonary hypertension, right ventricular systole lasts longer than LV systole causing downward motion of the septum early in diastole. If RV diastolic pressure is also elevated, as is the case in chronic pulmonary hypertension, the elevated pressure is present throughout systole and diastole, and the septum is persistently deformed and flattened. Fig 6.5

Question 15

Septal flattening:
Pressure overload from pulmonary hypertension:

-Flattening during …………….

Volume overload:
-Flattening during …………..

Answer 15

Septal flattening:
Pressure overload from pulmonary hypertension:

-Flattening during diastole and systole

Volume overload:
-Flattening during diastole

Question 16

The paradoxical septal motion can be evaluated using an eccentric index, which is increased in PH. Eccentricity is evaluated by comparing the ratio of the two minor axes of the LV on parasternal transverse views using the equation?

Answer 16

Eccentricity index = D2/D1

where D2 is the minor axis measured on transverse views of the LV at the level of the chordae tendineae in an axis parallel to the septum and D1 is the axis bisecting the septum and perpendicular to D2.
This is measured in systole and diastole.

Question 17

Normal eccentricity index during systole and diastole is …., meaning that the ventricle maintains its round shape throughout the cardiac cycle.

Answer 17

Normal eccentricity index during systole and diastole is 1, meaning that the ventricle maintains its round shape throughout the cardiac cycle.

Question 18

Right ventricular volume overload causes the left ventricular chamber to be less circular during systole. therefore, its eccentricity index is …………. during diastole.

Answer 18

Right ventricular volume overload causes the left ventricular chamber to be less circular during systole. therefore, its eccentricity index is increased during diastole. Fig 6.6

Question 19

Pulmonary hypertension deforms the septum during systole and diastole creating an eccentricity index that is ……………. throughout the cardiac cycle. These alterations in shape and motion can also be documented on ………….. where timing of the motion may be easier.

Answer 19

Pulmonary hypertension deforms the septum during systole and diastole creating an eccentricity index that is increased throughout the cardiac cycle. These alterations in shape and motion can also be documented on M-mode images where timing of the motion may be easier.

Question 20

Eccentricity index:

D2=

Answer 20

axis across LV at chordae

Question 21

Eccentricity index:

D1=

Answer 21

axis perpendicular to D2

Question 22

Eccentricity index:

Normal D2/D1 =

Answer 22

ca 1

Question 23

Eccentricity index:

D2/D1 > 1=

Answer 23

flattening

Question 24

Elevated right atrial pressure causes the inteatrial septum to curve toward the left atrial chamber. This creates the appearance of a ……….. LA chamber.

Answer 24

Elevated right atrial pressure causes the interatrial septum to curve toward the left atrial chamber. This creates the appearance of a small LA chamber.
Fig 6.2
The mitral annulus may also become distorted, and mitral valve prolapse may be present even with normal valvular strucute. Fig 6.2
The prolapse usually disappears after resolution of the pulmonary hypertension and return of normal septal motion.

Question 25

Elevated right atrial pressure often causes pericardial ………… and coronary sinus ………….. in man. The degree of pericardial effusion is directly correlated to RA pressure elevation.

Answer 25

Elevated right atrial pressure often causes pericardial effusion and coronary sinus dilation in man. The degree of pericardial effusion is directly correlated to RA pressure elevation.
The diameter of the coronary sinus is directly related to right atrial pressure and size and pulmonary artery systolic pressure.

Question 26

Chronic RV systolic pressure overload leads to compensatory RV hypertrophy (Fig 6.2). RV dilation commonly develops over time.

Answer 26

Chronic RV systolic pressure overload leads to compensatory RV hypertrophy (Fig 6.2). RV dilation commonly develops over time. Fig 6.3, 6.8

Question 27

Does the lack of RV hypertrophy rule out the presence of pulmonary hypertension?

Answer 27

No.
In one study, only half of 53 dogs had visible evidence of increased wall thickness.
Hypertrophy appears to be more common in young dogs than older dogs. This may suggest a different compensatory response to elevated pressure.

Question 28

Increased RV volume is subjectively determined from apical 4 ch views when the area of the RV is larger than the area of the LV. Fig 6.9

An apex that includes the RV chamber is also indicative of ………………..

Answer 28

Increased RV volume is subjectively determined from apical 4 ch views when the area of the RV is larger than the area of the LV. Fig 6.9

An apex that includes the RV chamber is also indicative of RV volume overload.

Question 29

2D evaluation of RV fractional ……………. is decreased in human patients with significant pulmonary hypertension.

Answer 29

2D evaluation of RV fractional area shortening is decreased in human patients with significant pulmonary hypertension.

Question 30

Fractional area change is calculated by tracing the area of the ventricular chamber in diastole (RVAd) and systole (RVAs) and applying equation 6.2

Answer 30

RV fractional area change =

(RVAd-RVAs)/RVAd x 100

Question 31

Fractional area change of the RV chamber should be ca ………… %. This is not always an accurate assessment of function however since the interaction of right and left ventricular pressure alters ………… conformation.

Answer 31

Fractional area change of the RV chamber should be ca 40-45%. This is not always an accurate assessment of function however since the interaction of right and left ventricular pressure alters septal conformation.

There is also a large range of normal values and no significant correlation with pulmonary artery pressure in man.

Question 32

In man, preserved apical function with hypokinesis of the rest of the RV chamber is relatively specific for massive acute ……..

Answer 32

In man, preserved apical function with hypokinesis of the rest of the RV chamber is relatively specific for massive acute PTE.

Question 33

RV dysfunction is not specific for pulmonary hypertension, and …..or….. should be ruled out.

Answer 33

RV dysfunction is not specific for pulmonary hypertension, and dysplasia or infarction should be ruled out.

In man there is a significantly increased risk of mortality when RV dysfunction is present compared to pulmonary hypertensive patients with preserved function.

Question 34

The main …………..and sometimes its proximal branches are dilated with chronic and acute elevations i pulmonary vascular pressure.

Answer 34

The main pulmonary artery and sometimes its proximal branches are dilated with chronic and acute elevations i pulmonary vascular pressure.
Figures 6.10, 6.11, 6.12.

Question 35

The normal relationship of pulmonary artery diameter to aortic root diameter in the dog is?

Answer 35

0.8-1.15.

With pulmonary hypertension this ratio becomes greater.

Question 36

Dilation of the pulmonary artery helps differentiate right heart enlargement secondary to tricuspid valve disease from pulmonary disease. How?

Answer 36

Tricuspid insufficiency without hypertension will not cause the pulmonary artery to dilate and may even cause may even cause it to be smaller than normal if the regurgitation is severe and forward flow is compromised.

The pulmonary valve may prolapse and balloon back toward the right ventricular chamber. Fig 6.10, 6.11. the prolapse is not specific for pulmonary hypertension however, and may also be seen with PDA and pulmonic stenosis.

Question 37

RA and RV enlargement without pulmonary artery dilation is not consistent with pulmonary hypertension.

Answer 37

RA and RV enlargement without pulmonary artery dilation is not consistent with pulmonary hypertension.

Question 38

There is evidence in man that acute PTE can be differentiated from chronic for pulmonale based on the appearance of the vena cava. ………. of the vena cava during inspiration suggests acute PTE whereas ………. of the vena cava during inspiration suggests chronic pressure overload of the right ventricle.

Answer 38

There is evidence in man that acute PTE can be differentiated from chronic for pulmonale based on the appearance of the vena cava. Dilation of the vena cava during inspiration suggests acute PTE whereas collapse of the vena cava during inspiration suggests chronic pressure overload of the right ventricle.

Question 39

Tricuspid annular plane systolic excursion (TAPSE) has been used in man as a predictor of survival in patients with …………………….

Answer 39

Tricuspid annular plane systolic excursion (TAPSE) has been used in man as a predictor of survival in patients with pulmonary arterial hypertension.

Question 40

Tricuspid annular motion is obtained by placing an M-mode cursor over the tricuspid annulus and measuring its ……………………. during systole. In man, a value of

Answer 40

Tricuspid annular motion is obtained by placing an M-mode cursor over the tricuspid annulus and measuring its amplitude of motion during systole.
. In man, a value of

Question 41

LV chamber size is usually small, and wall and septal thicknesses are typically increased in dogs with moderate to severe PH. This is presumably due to?

Answer 41

Poor preload.

Fig 6.2, 6.3

Question 42

There is only a weak correlation between the severity of PH secondary to left heart failure caused by MMVD and LV end systolic and end diastolic volume indexes or LA to aortic root ration. (r= 0.129, 0.242, and 0.242, respectively).

Answer 42

There is only a weak correlation between the severity of PH secondary to left heart failure caused by MMVD and LV end systolic and end diastolic volume indexes or LA to aortic root ration. (r= 0.129, 0.242, and 0.242, respectively).
Volume indexes were calculated with the Teicholz equation from M-mode diastolic and systolic chamber sizes.

Question 43

Systolic time intervals may also be abnormal in dogs with moderate to severe pulmonary hypertension. M-mode derived pre-ejection time (LVPEP) ………….., ejection time (LVET) ………………., and the ratio of LVPEP:LVET ……..

Answer 43

Systolic time intervals may also be abnormal in dogs with moderate to severe pulmonary hypertension. M-mode derived pre-ejection time (LVPEP) increased, ejection time (LVET) decreases, and the ratio of LVPEP:LVET increases.
These are thought to be more likely due to poor preload than systolic failure.

Question 44

A study in Greenland dogs at high altitude tends to suggest that LV systolic function may be enhanced since these dogs had decreased LVPEP:LVET secondary to decreased LVPEP. LV chamber size was not different from control in these dogs with PH. These systolic time intervals were obtained from spectral Doppler evaluation of aortic flow.
Sympathetic influences were thought to play a role in these findings.

Answer 44

A study in Greenland dogs at high altitude tends to suggest that LV systolic function may be enhanced since these dogs had decreased LVPEP:LVET secondary to decreased LVPEP. LV chamber size was not different from control in these dogs with PH. These systolic time intervals were obtained from spectral Doppler evaluation of aortic flow.
Sympathetic influences were thought to play a role in these findings.

Question 45

Others have found normal echo parameters of LV function despite poor preload, and the thought is that there is decreased afterload secondary to decreased preload, poor output, and hypotension.
Volume cannot move into the left side of the heart when significant pulmonary hypertension is present.

Answer 45

Others have found normal echo parameters of LV function despite poor preload, and the thought is that there is decreased afterload secondary to decreased preload, poor output, and hypotension.
Volume cannot move into the left side of the heart when significant pulmonary hypertension is present.

Question 46

Doppler evaluation:
Tricuspid regurgitation is almost always present when there is PH. It ranges from mild to severe. This regurgitation may be secondary to?

Answer 46

Annular stretch

Changes in right ventricular geometry

Question 47

Is the severity of tricuspid insufficiency always correlated with the severity of the pulmonary hypertension?

Answer 47

The severity of the tricuspid insufficiency does not always correlate with the severity of the pulmonary hypertension, but decreases in pressure do change the severity of the regurgitation, especially when the cause of the regurgitation was annular dilation.

Question 48

Applying the Bernoulli equation to the velocity of a tricuspid regurgitant jet provides an estimate of ……………

Answer 48

Applying the Bernoulli equation to the velocity of a tricuspid regurgitant jet provides an estimate of RV systolic pressure.

Question 49

Applying the Bernoulli equation to the velocity of a tricuspid regurgitant jet provides an estimate of RV systolic pressure.
In the absence of pulmonary outflow obstruction, this RV pressure is equal to …………………………. pressure.

Answer 49

In the absence of pulmonary outflow obstruction, this RV pressure is equal to peak pulmonary artery systolic pressure.
Fig 6.13

Use the imaging plane that most accurately aligns the Doppler cursor with the regurgitant jet. This may not always be obvious and flow velocities from several imaging planes should be tried.

Question 50

A good TR flow profile should be ………….. in shape and encompass at …………….. of ………

Answer 50

A good TR flow profile should be parabolic in shape and encompass at least half of systole.

Question 51

Use tricuspid insufficiency flow velocities to determine the pressure within the RV and pulmonary artery

Answer 51

Use tricuspid insufficiency flow velocities to determine the pressure within the RV and pulmonary artery

Question 52

Pulmonary insufficiency: Mean pulmonary artery pressure is derived from ………. …………………. velocity and is approximately equal to pulmonary wedge pressure while diastolic pulmonary artery pressure is derived from the …………………. velocity and pressure gradient.

Answer 52

Pulmonary insufficiency: Mean pulmonary artery pressure is derived from early peak pulmonary regurgitant flow velocity and is approximately equal to pulmonary wedge pressure while diastolic pulmonary artery pressure is derived from the end diastolic velocity and pressure gradient.

Fig 6.14

Question 53

Pulmonary regurgitant flow:

Peak early pressure gradient:

• ……………artery pressure
• reflects …………ressure

Answer 53

• mean pulmonary artery pressure

- reflects pulmonary wedge pressure

Question 54

Pulmonary regurgitant flow:

End diastolic pressure gradient:
-diastolic ………………. pressure

Answer 54

End diastolic pressure gradient:

-diastolic pulmonary artery pressure

Question 55

Underestimation of systolic or diastolic pulmonary artery pressure is possible when?

Answer 55

Underestimation of systolic or diastolic pulmonary artery pressure is possible when the Doppler cursor is not aligned optimally (parallel) with the regurgitant jet.

Question 56

Severe regurgitant volume may also lead to overestimation of the pressure since the modified Bernoulli equation does not take into consideration the ……………………that may be significantly elevated and not negligible.

Answer 56

Severe regurgitant volume may also lead to overestimation of the pressure since the modified Bernoulli equation does not take into consideration the proximal flow acceleration that may be significantly elevated and not negligible.

Question 57

Estimated pulmonary artery pressure in man is dependent upon body mass, gender, and age, as well as several cardiac parameters including LV ……….. and LV ………………….

Answer 57

Estimated pulmonary artery pressure in man is dependent upon body mass, gender, and age, as well as several cardiac parameters including LV free wall thickness and LV ejection fraction.

Question 58

Estimation of pulmonary vascular resistance (PVR) has been reported in man using Doppler and 2D echo. Pulmonary vascular resistance in Woods units is calculated using equation 6.3

Answer 58

Estimation of pulmonary vascular resistance (PVR) has been reported in man using Doppler and 2D echo. Pulmonary vascular resistance in Woods units is calculated using equation 6.3

Using this equation, if the tricuspid regurgitant jet has a velocity of 2.86 m/sec and the RV outflow tract flow velocity integral is 20,8 cm, the ratio of TRvmax :RVOTfvi would equal 0.1375
Inserting this value into Equaiton 6.3 would yield…. s

PVR values greater than 2 are considered to be elevated. This had a specificity of 94%.

Question 59

Calculation of PVR may eliminate the overestimation of PH in hyper dynamic hearts and hearts with significant regurgitant volumes and underestimation of PH in hearts with right heart failure and low output.

Answer 59

Calculation of PVR may eliminate the overestimation of PH in hyper dynamic hearts and hearts with significant regurgitant volumes and underestimation of PH in hearts with right heart failure and low output.

Whether using these equations in dogs is applicable remains to be studied.

Question 60

Another method of calculating PVR uses Equations 6.4 and 6.5.

Answer 60

Equations 6.4 and 6.5

Whether using these equations in dogs is applicable remains to be studied.

Question 61

Pulmonary flow profiles change as pulmonary hypertension develops. All dogs with pulmonary hypertension in one study showed rapid pulmonary artery systolic flow ……….. This is seen secondary to the elevated rate of rise of right ventricular systolic pressure with the start of RV ejection.

Answer 61

Pulmonary flow profiles change as pulmonary hypertension develops. All dogs with pulmonary hypertension in one study showed rapid pulmonary artery systolic flow acceleration. This is seen secondary to the elevated rate of rise of right ventricular systolic pressure with the start of RV ejection.

Question 62

A normal pulmonary artery flow profile with peak flow velocity occurring approximately half way throughout systole is called?

Answer 62

a Type I flow profile.

Question 63

A rapidly accelerating pulmonary artery flow profile is called?

Answer 63

Type II

Fig 6.15

Question 64

This rapidly accelerating pulmonary artery flow results in abnormal right ventricular systolic time intervals including …………..(3)

Answer 64

This rapidly accelerating pulmonary artery flow results in abnormal right ventricular systolic time intervals including time to peak flow (AT), pre-ejection period, ejection time, and acceleration rate.

These all correlated with pulmonary artery pressure in man and in dogs.

Question 65

Acceleration time (AT) is shortened and the ratio of AT:RVET is decreased in dogs with PH. Is this a reliable indication of PH?

Answer 65

It is not always reliable indication of pulmonary hypertension as the shorter time interval and ratio may be found in normal healthy dogs as well.

Question 66

Statistically, the predictive value of AT appears to be more sensitive (80=%) and specific (80%) in dogs for predicting PH at a cutoff value of …. msec that AT:RVET.
Values less than ……msec predict the presence of PH.

Answer 66

Statistically, the predictive value of AT appears to be more sensitive (80=%) and specific (80%) in dogs for predicting PH at a cutoff value of 80 msec that AT:RVET.
Values less than 80 msec predict the presence of PH. Table 6.1

Question 67

Another study in dogs however, showed good correlation between the ratio of acceleration time to ejection time (AT/RVET) and pulmonary artery pressures.
Simply using acceleration time alone did not yield as good a correlation with pulmonary pressures even though the time did decrease with increasing pressures.

Answer 67

Another study in dogs however, showed good correlation between the ratio of acceleration time to ejection time (AT/RVET) and pulmonary artery pressures.
Simply using acceleration time alone did not yield as good a correlation with pulmonary pressures even though the time did decrease with increasing pressures.

The correlation coefficient between AT/RVET and systolic pulmonary artery pressures is 0.84.

Question 68

Pulmonary artery flow acceleration time increases with hypertension:

Type 1: …………………

Type II: rapid ………… time. AT

Answer 68

Type 1: Normal flow profile

Type II: rapid acceleration time. AT

Question 69

Pulmonary artery flow deceleration may appear normal or may have mid to late systolic notching. The presence of systolic notching defines the flow profile as a ….

Answer 69

Type III.

Fig 6.17

Question 70

This notching of the pulmonary flow profile in mid to late systole is due to partial tempory closure of the …………. and is fondly called the” flying …….”

Answer 70

This notching of the pulmonary flow profile in mid to late systole is due to partial tempory closure of the pulmonary valve and is fondly called the” flying W”

Question 71

The notching of the pulmonary flow profile is thought to be caused by?

Answer 71

Caused by high pulmonary vascular resistance and reflected systolic pressure from the proximal pulmonary arteries.

Question 72

There are reports of notching during pulmonary flow deceleration in dogs with normal pulmonary artery pressure. This is hypothesized to be gate location dependent, with changes in flow profiles occurring when the gate is placed too close to the ….. wall or too far into the …………….

Answer 72

There are reports of notching during pulmonary flow deceleration in dogs with normal pulmonary artery pressure. This is hypothesized to be gate location dependent, with changes in flow profiles occurring when the gate is placed too close to the lateral wall or too far into the pulmonary artery.

Question 73

Paradoxical septal motion with flattening of the septum during diastole affects LV diastolic function. Early diastolic filling is decreased, and the transmittal E wave is …………… while the atrial contraction, contributing more to LV filling, is represented by a ………. A wave.

Answer 73

Early diastolic filling is decreased, and the transmittal E wave is diminished while the atrial contraction, contributing more to LV filling, is represented by a high A wave.
Fig 6.18

Question 74

Paradoxical septal motion with flattening of the septum during diastole affects LV diastolic function.
This decrease in LV filling is a major contributor to the pronounced decrease in LV ……………t seen with acute pulmonary hypertension secondary to massive PTE.

Answer 74

This decrease in LV filling is a major contributor to the pronounced decrease in LV cardiac output seen with acute pulmonary hypertension secondary to massive PTE

Question 75

In man, studies have shown that the mitral valve E:A ratio correlates directly with cardiac …….. and inversely with pulmonary ………… pressure.

Answer 75

In man, studies have shown that the mitral valve E:A ratio correlates directly with cardiac output and inversely with pulmonary artery pressure.

Question 76

Chronic pulmonary hypertension usually has preserved RV systolic function as the heart slowly remodels in response to chronic pressure increases. As a result, transmitral E waves can be ………………in these patients compared with acute pulmonary hypertension.

Answer 76

Chronic pulmonary hypertension usually has preserved RV systolic function as the heart slowly remodels in response to chronic pressure increases. As a result, transmitral E waves can be normal in these patients compared with acute pulmonary hypertension.

Question 77

Differentiating chronic from acute pulmonary hypertension is difficult.
Acute pulmonary hypertension secondary to thromboembolic (PTE) events results in ….

Answer 77

RV volume overload, a dilated pulmonary artery, usually TR, RV hypokinesis, paradoxical systolic motion, and septal flattening.

Question 78

Differentiating chronic from acute pulmonary hypertension is difficult.
Chronic hypertension leads to…?

Answer 78

RV hypertrophy with eventual dilation and systolic failure

Question 79

Distensibility of the pulmonary artery has been used in man to differentiate patients with chronic pulmonary hypertension from those with acute pulmonary hypertension secondary to thromboembolic events (PTE).

Where is the distensibility measured?

Answer 79

As the maximal systolic pulmonary artery diameter minus the minimal diastolic pulmonary artery diameter. The measurements are made in the main pulmonary artery segment, 2 to 3 cm distal to the valve, in a view that shows the bifurcation. Fig 6.19

Question 80

Distensibility in patients with chronic pulmonary hypertension is low while the vessel is more reactive when pulmonary artery pressure elevates secondary to PTE.

Answer 80

Distensibility in patients with chronic pulmonary hypertension is low while the vessel is more reactive when pulmonary artery pressure elevates secondary to PTE.

Distensibility is still lower in both of these causes of hypertension when compared to the pulmonary artery of normal individuals. In this study, the pulmonary artery remained dilated in patients with acute PTE, but distensibility improved after 3 months of anticoagulation therapy

Question 81

Pulmonary artery distensibility:

May help differentiate chronic pulmonary hypertension from acute pulmonary hypertension secondary to PTE

Answer 81

Pulmonary artery distensibility:

May help differentiate chronic pulmonary hypertension from acute pulmonary hypertension secondary to PTE

Question 82

Tissue Doppler:
There is a relationship between TDI parameters of the RV myocardium and pulmonary hypertension. Using a 2- by 2-mm gate places at the level of the tricuspid annulus in the middle 0f the myocardium, color-tissue variables have been studied and use to predict the presence and degree of pulmonary hypertension in dogs.

Answer 82

There is a relationship between TDI parameters of the RV myocardium and pulmonary hypertension. Using a 2- by 2-mm gate places at the level of the tricuspid annulus in the middle 0f the myocardium, color-tissue variables have been studied and use to predict the presence and degree of pulmonary hypertension in dogs.

Question 83

The RV Tei index using color-tissue Doppler has been studied in dogs with normal PAP and dogs with PH. (Equation 4.29).

A Tei index (MPI) of ……. is the cutoff value, with a value greater than this predicting PH with a specificity of 80% and a sensitivity of 78%.

Answer 83

A Tei index (MPI) of 0.25 is the cutoff value, with a value greater than this predicting PH with a specificity of 80% and a sensitivity of 78%.

Question 84

Global TDI derived by equation 6,7, is statistically different between dos with normal, mildly elevated, and significantly elevated PAP. Fig 6.20

Answer 84

Global TDI =
S´x E/A´

The systolic (S´) and diastolic waves (E´and A´) are obtained from color TDI of the RV wall at the tricuspid annulus.

Question 85

………………..TDI has the highest sensitivity (89%) and specificity (93%) at predicting the presence of PH at a cutoff of ….. cm. values less than this suggest PH. A cutoff value of 12,7 cm/sec can be used to differentiate equivocal PH from dogs with normal PAP with a specificity and sensitivity of 88% each.

table 6.1

Answer 85

Global TDI has the highest sensitivity (89%) and specificity (93%) at predicting the presence of PH at a cutoff of 11.8 cm. values less than this suggest PH. A cutoff value of 12,7 cm/sec can be used to differentiate equivocal PH from dogs with normal PAP with a specificity and sensitivity of 88% each.

Question 86

Color TDI RV Tei index:

> …… is consistent with pulmonary hypertension

Answer 86

> 0.25 is consistent with pulmonary hypertension

Question 87

Global Color TDI

Question 88

Tissue doppler tricuspid systolic annular velocity (S´) is altered in patients with pulmonary hypertension in man and in dogs. A cutoff value of 10.5 cm/sec however is only 69% and 68% sensitive and specific in dogs, respectively.

Answer 88

Tissue doppler tricuspid systolic annular velocity (S´) is altered in patients with pulmonary hypertension in man and in dogs. A cutoff value of 10.5 cm/sec however is only 69% and 68% sensitive and specific in dogs, respectively.

Question 89

Color-tissue Doppler E´:A´however is more predictive of PH (89% sens and 90% specific) at a threshold of 1.12. Values lower than 1.12 are consistent with the diagnosis of ?

Answer 89

Elevated pulmonary artery pressure.

Fig 6.20

Question 90

LA pressure can be estimated using TDI and transmittal flow PW signals. An E:E´ratio of less than …… in dogs is consistent with normal pulmonary venous pressure while a value higher than that is consistent with possible pulmonary ……….. hypertension as a potential cause of pulmonary ………… hypertension.

Answer 90

LA pressure can be estimated using TDI and transmittal flow PW signals. An E:E´ratio of less than 6 in dogs is consistent with normal pulmonary venous pressure while a value higher than that is consistent with possible pulmonary venous hypertension as a potential cause of pulmonary arterial hypertension.

There is much overlap in pressure between ratios of 6 and 7. In man, this ratio is 95% sens and 96% specific for separating normal from abnormal pulmonary venous hypertension.

Question 91

Heartworms:

When heart worms are the underlying cause of PH, they can at times be detected on 2D echo images. Although M-mode images can document the presence of heart worms within the right side of the heart, 2D images are more sensitive.

Answer 91

Although M-mode images can document the presence of heart worms within the right side of the heart, 2D images are more sensitive.

Question 92

Linear echoes representing the worms can be seen within the chambers of the right heart. The linear echoes are typically two parallel lines separated by a very thin hypo echoic area.

Answer 92

Fig 6.21

Question 93

When the heart worm load is massive, the worms may be displayed as an echogenic mass within the chambers. This mass may be seen moving
back and forth within the chambers, the pulmonary artery, or through the tricuspid annulus as flow varies during systole and diastole.

Answer 93

Fig 6.22

Question 94

Does the absence of echocardiographically displayed heart worms support the absence of the worms?

Answer 94

The absence of echocardiographically displayed heart worms does not support the absence of the worms. if the ultrasound beam is not directed perpendicular to the worms, they may not be detected. Additionally, if the heart worms are within the pulmonary arteries beyond the bifuctioan, they will also not be seen.

Question 95

Systemic hypertension:

Typically secondary to other diseases with renal failure, diabetes, and hyperthyroidism being the most common.

Answer 95

Systemic hypertension:

Typically secondary to other diseases with renal failure, diabetes, and hyperthyroidism being the most common.

Question 96

The definition of what constitutes systemic hypertension is variable. Pressures ranging from 150/90 to 180/100 and up are all define as hypertensive in various canine studies.
Hypertension is usually defined as systolic blood pressure above 160 or 180 mmHg in the cat.

Answer 96

The definition of what constitutes systemic hypertension is variable. Pressures ranging from 150/90 to 180/100 and up are all define as hypertensive in various canine studies.
Hypertension is usually defined as systolic blood pressure above 160 or 180 mmHg in the cat.

Question 97

2D and M-mode features:

Chronic increases in afterload caused by systemic hypertension leads to compensatory myocardial hypertrophy in order to normalize wall stress (figures 6.23, 6.24)

Answer 97

Chronic increases in afterload caused by systemic hypertension leads to compensatory myocardial hypertrophy in order to normalize wall stress (figures 6.23, 6.24)

Question 98

Although logic would suggest that the degree of LV hypertrophy would be directly related to the degree of hypertension, studies have shown that the development of hyperthropy does not correlate linearly to the development of pressure.

Answer 98

Although logic would suggest that the degree of LV hypertrophy would be directly related to the degree of hypertension, studies have shown that the development of hyperthropy does not correlate linearly to the development of pressure.

Question 99

Other factors including …… and …….. influences play a role in the development of wall thickness to compensate for the elevation in pressure.

Answer 99

Other factors including neural and humoral influences play a role in the development of wall thickness to compensate for the elevation in pressure.

Question 100

Studies have also shown that the elevation in pressure during daily normal activities in patients with …….. hypertrophy is less than the pressure elevation in patients with ……….. hypertrophy.

Answer 100

Studies have also shown that the elevation in pressure during daily normal activities in patients with eccentric hypertrophy is less than the pressure elevation in patients with concentric hypertrophy.

Question 101

Which type of hypertrophy may be seen with systemic hypertension?

Answer 101

Concentric or eccentric

Question 102

Systemic hypertension in cats causes overall alterations in LV shape, concentric LV hypertrophy involving the septum and the free wall, and a small LV chamber size.

Answer 102

Systemic hypertension in cats causes overall alterations in LV shape, concentric LV hypertrophy involving the septum and the free wall, and a small LV chamber size.

Question 103

Which type of hypertrophy pattern is seen in hypertensive cats?

Answer 103

The type of hypertrophy pattern varies in hypertensive cats, from asymmetric and symmetric hypertrophy involving the septum or free wall, eccentric hypertrophy, and hypertrophy that involves only the base of the inter ventricular septum. This hypertrophy cannot be differentiated from that seen in hypertrophic cardiomyopathy.

Several echo studies in cats with systemic hypertension showed the following forms of LV hypertrophy. Some cats showed no ventricular changes from normal, other cats showed concentric hypertrophy that was symmetric or asymmetric. Of the asymmetric patterns of hypertrophy, more displayed hypertrophy of the free wall than hypertrophy of the septum.

Question 104

Eccentric hypertrophy, which means a dilated LV chamber with or without hypertrophic changes of the septum or wall, was seen in 13% of cats with systemic hypertension.
Localized septal hypertrophy at the base of the inter ventricular septum was the inly hypertrophic change seen in normal older cats.

Answer 104

Eccentric hypertrophy, which means a dilated LV chamber with or without hypertrophic changes of the septum or wall, was seen in 13% of cats with systemic hypertension.
Localized septal hypertrophy at the base of the inter ventricular septum was the inly hypertrophic change seen in normal older cats.
Fig 6.25

Question 105

Although the highest blood pressure was seen in cats with eccentric hypertrophy in one study, there was no statistical difference between the types of hypertrophy and the degree or type of hypertrophy and level of blood pressure elevation in any study in the cat. It did appear that cats with eccentric enlargement were younger than the rest of the hypertensive cats.

Answer 105

Although the highest blood pressure was seen in cats with eccentric hypertrophy in one study, there was no statistical difference between the types of hypertrophy and the degree or type of hypertrophy and level of blood pressure elevation in any study in the cat. It did appear that cats with eccentric enlargement were younger than the rest of the hypertensive cats.

Question 106

Although not studied in cats, there is a greater risk of cardiovascular-related death in human patients with hypertrophy, and the degree of septal thickness is considered to be one of the most important 2D and M-mode predictors of cardiac death secondary to systemic hypertension.

Answer 106

Although not studied in cats, there is a greater risk of cardiovascular-related death in human patients with hypertrophy, and the degree of septal thickness is considered to be one of the most important 2D and M-mode predictors of cardiac death secondary to systemic hypertension.

Question 107

The degree of hypertrophy and its variable appearance seen in cats with hypertension may be affected by the chronicity. Studies in dogs have shown that hypertrophy develops over the course of about …… in response to the hypertension.

Answer 107

6 weeks

Question 108

The degree of variability in hypertrophic patterns or the lack there of in cats with hypertension make echocardiography an unlikely screening method. Having said this however, it is probably wise to check blood pressure in an animal that shows unexplained hypertrophy in an echo study.

Answer 108

The degree of variability in hypertrophic patterns or the lack there of in cats with hypertension make echocardiography an unlikely screening method. Having said this however, it is probably wise to check blood pressure in an animal that shows unexplained hypertrophy in an echo study.

Question 109

Systolic dysfunction is also present in hypertensive human patients. Studies in dogs show that systolic function is preserved, although chronicity was not looked at. Eventual myocardial failure may be anticipated as wall stress becomes elevated.

Answer 109

Systolic dysfunction is also present in hypertensive human patients. Studies in dogs show that systolic function is preserved, although chronicity was not looked at. Eventual myocardial failure may be anticipated as wall stress becomes elevated.

Question 110

Systolic dysfunction occurs after the onset of ……….. impairment.

Answer 110

Systolic dysfunction occurs after the onset of diastolic impairment.

Question 111

Fractional shortening cannot be used as an indicator of systolic dysfunction in hypertensive cats.

………….. in systolic and eventually diastolic chamber sizes as well as ………..systolic thickening of the wall and septum indicate that systolic dysfunction is present, despite normal fractional shortening.

Answer 111

Increases in systolic and eventually diastolic chamber sizes as well as decreased systolic thickening of the wall and septum indicate that systolic dysfunction is present. despite normal fractional shortening.

Question 112

Hypertension:
Systolic dysfunction:
Congestive heart failure is the result. This systolic impairment may be secondary to impaired myocardial ………, the result of changes in the small …….. vessels or ……………..afterload and wall stress in patients without adequate compensatory hypertrophy.

Answer 112

Congestive heart failure is the result. This systolic impairment may be secondary to impaired myocardial perfusion, the result of changes in the small coronary vessels or increased afterload and wall stress in patients without adequate compensatory hypertrophy.

Question 113

When hypertension is treated appropriately, hypertrophy will regress and diastolic function will improve. Improvement of diastolic function as hypertrophy regresses is secondary to the………afterload and better rate of myocardial relaxation.

Answer 113

When hypertension is treated appropriately, hypertrophy will regress and diastolic function will improve. Improvement of diastolic function as hypertrophy regresses is secondary to the reduced afterload and better rate of myocardial relaxation.

Question 114

Hypertension:
Systolic function determined with M-mode echo is variable in cats, and although most have normal function, fractional shortening ranges from normal to normal and high.

Answer 114

Systolic function determined with M-mode echo is variable in cats, and although most have normal function, fractional shortening ranges from normal to normal and high.

Question 115

Left atrial size in cats with hypertension is usually normal but may be large in some. This may be secondary to…? (3)

Answer 115

ventricular remodeling, diastolic failure, or mitral regurgitation.

Question 116

Although the degree of LV hypertrophy does not correlate with the degree of hypertension, ………….. size in cats does.

An M-mode measurement at the level of the aortic valve may not reflect this change. 2D assessment of the long-axis LV outflow view is necessary to document this dilation, and comparison of the ……… aorta to the aorta at the level of the ……. is necessary.

Answer 116

Although the degree of LV hypertrophy does not correlate with the degree of hypertension, ascending aortic size in cats does.

An M-mode measurement at the level of the aortic valve may not reflect this change. 2D assessment of the long-axis LV outflow view is necessary to document this dilation, and comparison of the ascending aorta to the aorta at the level of the annulus is necessary. Fig 6.26.

it can be used to differentiate cats with systemic hypertension from those without.

Question 117

The aorta is measured at the annulus and the sinus of Valsalva, as well as the sinotubular junction and the ascending aorta just beyond the sinotubular junction.

Answer 117

The aorta is measured at the annulus and the sinus of Valsalva, as well as the sinotubular junction and the ascending aorta just beyond the sinotubular junction.

Question 118

Measurements at the sinotubular junction and the ascending aorta were larger in all cats with systemic hypertension, while measurements taken at the valve annulus and the sinus were no different in hypertensive cats than normal cats.

Answer 118

Measurements at the sinotubular junction and the ascending aorta were larger in all cats with systemic hypertension, while measurements taken at the valve annulus and the sinus were no different in hypertensive cats than normal cats.

Question 119

Normal cats have 2D measurements of 7.6 +/- 0.6 mm at the sinotubular junction and the ascending aorta while cats with systemic hypertension had measurements of 9.2 +/- 1.1 mm and 9.7 +/- 1.2 mm, respectively.

Answer 119

Normal cats have 2D measurements of 7.6 +/- 0.6 mm at the sinotubular junction and the ascending aorta while cats with systemic hypertension had measurements of 9.2 +/- 1.1 mm and 9.7 +/- 1.2 mm, respectively.

Question 120

Ratios of the sinotubular dimension to the aortic annulus and the ascending aorta to annulus werre 1.06 +/- 0.1 and 1.05 +/- 0.1, respectively, in normal cats while hypertensive cats had ratios of 1.26 +/-0.1 and 1.34 +/- 0.1 respectively.

Answer 120

Ratios of the sinotubular dimension to the aortic annulus and the ascending aorta to annulus werre 1.06 +/- 0.1 and 1.05 +/- 0.1, respectively, in normal cats while hypertensive cats had ratios of 1.26 +/-0.1 and 1.34 +/- 0.1 respectively.

No healthy cat of any age had a sinotubular to aortic annulus ratio of greater than 1.25.

Question 121

Feline normal blood pressure;
Sinotubular junction: aortic annulus:

Always

Question 122

Feline systemic hypertension:

Sinitubular dimension: aortic annulus:

Answer 122

1.26 +/- 0.1

Question 123

Feline systemic hypertension:

Ascending aorta:aortic annulus:

Answer 123

1.34 +/- 0.1

Question 124

Spectral Doppler:
Diastolic dysfunction in the setting of systemic hypertension has not been evaluated in animals, but has been documented as an early change in man with systemic hypertension before any hypertrophic changes or systolic failure have occurred.

Answer 124

Diastolic dysfunction in the setting of systemic hypertension has not been evaluated in animals, but has been documented as an early change in man with systemic hypertension before any hypertrophic changes or systolic failure have occurred.

Question 125

Spectral Doppler:
One study in man showed that transmittal E:A ratio decreased, pulmonary venous S: D ratio increased, pulmonary venous A reversal flow increased in duration, and isovolumic relaxation time increased in patients that developed mild hypertension over the course of a few years.

Answer 125

One study in man showed that transmittal E:A ratio decreased, pulmonary venous S:D ratio increased, pulmonary venous A reversal flow increased in duration, and isovolumic relaxation time increased in patients that developed mild hypertension over the course of a few years.

Question 126

Human patients often present in left-sided congestive heart failure secondary to systemic hypertension. Previously this was thought to be the consequence of impaired systolic function or exacerbated MR. This was found not to be the case in many patients however, and diastolic failure has been documented as a cause of left heart failure secondary to the presence of systemic hypertension.

Answer 126

This was found not to be the case in many patients however, and diastolic failure has been documented as a cause of left heart failure secondary to the presence of systemic hypertension.

The transmitral filling pattern in these patients reflects impaired relaxation but returns to a pseudonormal or restrictive pattern after treatment for heart failure.

Question 127

Bot a restrictive filling pattern and a pseudonormal filling pattern are associated with poor prognosis in human patients with systemic hypertension. This elevation in LV filling pressure is thought to be secondary to ………………

Answer 127

This elevation in LV filling pressure is thought to be secondary to hypertrophy, fibrosis, scaring, and increased wall stress. These transmitral flow patterns have the highest predictive value for cardiac-related mortality, over any other echo parameter, including tissue Doppler.

This parameter has not been studied in animals with systemic hypertension

Question 128

Increased isovolumic relaxation time (IVRT) is a common finding in humans with systemic hypertension. This parameter correlates highly with the degree of LV mass but not necessarily with the degree of wall thickness, and helped define diastolic dysfunction in the pseudonormal group of transmitral valve flow.

Answer 128

Increased isovolumic relaxation time (IVRT) is a common finding in humans with systemic hypertension. This parameter correlates highly with the degree of LV mass but not necessarily with the degree of wall thickness, and helped define diastolic dysfunction in the pseudonormal group of transmitral valve flow.

The increase in IVRT is not found in athletes with LV hypertrophy.

Question 129

CW Doppler of MR flow can be used to indirectly determine LV and systemic systolic pressure.

Answer 129

Fig 6.27

Alignment of the Doppler beam parallel with the regurgitant jet is imperative, otherwise systemic blood pressure will be underestimated.

Question 130

CW Doppler of MR flow:
Adding an estimated LA pressure to the calculated pressure gradient will yield the approximate systemic systolic pressure. If left atrial size is increased, this method is less accurate and these animals can not have any outflow obstruction.

Answer 130

Adding an estimated LA pressure to the calculated pressure gradient will yield the approximate systemic systolic pressure. If left atrial size is increased, this method is less accurate and these animals can not have any outflow obstruction.

It can be used to help in situations where peripheral blood pressure measurements are low and a regurgitant jet pressure gradient can be used to confirm pressure that is more normal.

Question 131

In the presence of mild to moderate mitral regurgitation where proximal flow acceleration is negligible, Doppler-derived systolic pressure can help confirm the diagnosis of systemic hypertension when a peripheral blood pressure cannot be obtained or is thought be inaccurate.

Answer 131

In the presence of mild to moderate mitral regurgitation where proximal flow acceleration is negligible, Doppler-derived systolic pressure can help confirm the diagnosis of systemic hypertension when a peripheral blood pressure cannot be obtained or is thought be inaccurate.

Question 132

TDI:

Diastolic dysfunction has been documented in systemically hypertensive human patients. TDI ………. annular velocity has been shown to be predictive of cardiovascular mortality in these patients.

Answer 132

Diastolic dysfunction has been documented in systemically hypertensive human patients. TDI diastolic annular velocity has been shown to be predictive of cardiovascular mortality in these patients.

Question 133

Significantly lower S´and E´myocardial annular velocities, especially E´, at both the lateral wall and the septum on 3 chamber apical views are associated with poor prognosis in man

Answer 133

Significantly lower S´and E´myocardial annular velocities, especially E´, at both the lateral wall and the septum on 3 chamber apical views are associated with poor prognosis in man

Question 134

TDI has been reported in one case of systemic hypertension in a dog. Longitudinal systolic myocardial motion (S´) was depressed in this dog while radial systolic myocardial motion was normal. This dog had eccentric LV enlargement and normal FS. and TD imaging was the only indicator of possible systolic dysfunction involving longitudinal fibers.

Answer 134

TDI has been reported in one case of systemic hypertension in a dog. Longitudinal systolic myocardial motion (S´) was depressed in this dog while radial systolic myocardial motion was normal. This dog had eccentric LV enlargement and normal FS. and TD imaging was the only indicator of possible systolic dysfunction involving longitudinal fibers.

The dog in this study did have an increased LV systolic dimension, which is usually considered to be an indicator of systolic myocardial dysfunction.

Question 135

Longitudinal fibers are thought to be more susceptible to ischemia and fibrosis as compared to radial fibers. This evidence of systolic dysfunction using TDI has been documented in man without a decrease in FS or radial fiber dysfunction as well.

Answer 135

Longitudinal fibers are thought to be more susceptible to ischemia and fibrosis as compared to radial fibers. This evidence of systolic dysfunction using TDI has been documented in man without a decrease in FS or radial fiber dysfunction as well.