Left Ventricle

Question 1

Cardinal LV movements?

Answer 1

Longitudinal
Circumferential
Radial thickening

Question 2

Fractional shortening?

Answer 2

1-dimensional 
(LVIDd-LVIDs)/(LVIDd)
> 25% = normal
PSLAX or PSAX
Inner edge to inner edge
Teicholz method; EF = FSx2 if no WMA

Question 3

Fractional area change

Answer 3

2-dimensional
(LVEDA - LVESA)/(LVEDA)
FAC > 35% = normal
PSAX. Trace area, include papillary muscles

Question 4

Ejection Fraction

Answer 4

3-dimensional
(LVEDV-LVESV)/(LVEDV)
A4C & A2C using Biplane method

Question 5

Tissue doppler S’

Answer 5

Mitral valve annulus excursion velocity

Normal values:
Lateral > 10 cm/s
Septal > 8 cm/s

Question 6

EPSS

Answer 6

M-mode perpendicular to tip of anterior mitral valve leaflet (A2)
PLAX
Normal < 8 mm

EPSS > 13 mm high PPV for EF < 35%

Question 7

Caveats with EPSS

Answer 7

Falsely elevated in MS, AI, and dilated cardiomyopathy

Question 8

Load dependency of dP/dT?

Answer 8

Preload dependent
Afterload independent
Need MR jet

Question 9

What is dP/dT?

Utility of dP/dT?

Answer 9

Rate of pressure rise in systole

measure of contractility independent of afterload

Question 10

how to calculate dP/dT?

Limitations?

Answer 10

dP = difference b/t pressures at 100 cm/s and 300 cm/s = 32 mmHg
dT = time it takes for pressure to increase from 4 mmHg to 36 mmHg
Numerator ALWAYS 32.
Need to be very precise and accurate with measurement of will get wildly inaccurate measurement (this is LIMITATION).

Normal typically > 1000 mmHg/s

Question 11

Velocity of circumferential thickening

Benefit?

Answer 11

FS equation with ejection time (ET) in denominator

VCT = (LVIDd-LVIDs)/(LVIDd)(ET)

Less preload dependent than EF

Question 12

What are the load INDEPENDENT measurements of LV systolic function?

Answer 12

End-systolic elastance
Recruitable stroke work
Strain rate

Question 13

LVOT VTI

Answer 13

Measure of how far the RBC travel in LVOT during systole
Used to calculate stroke volume or as independent measure of contractility

Normal 18-22 cm for HR 55-95

Question 14

Normal values for LVIDd, LVEDA, and LV wall thickness

Where do you measure LV wall thickness?

Answer 14

LVIDd = 4-6 cm
LVEDA = 30-40 cm2
LV septum = < 1.1 cm
Inferior wall = < 1.1

PSLAX, distal to MV leaflet tip, in diastole (inf & septum)
PSAX, septum only, in diastole

Question 15

Most common non-primary cardiac tumors?
Highest rate of pericardial mets?
Which cancer can extend from IVC into RA?

Answer 15

Metastatic tumor 20x more likely. Lung > lymphoma > breast
Melanoma HIGHEST rate of pericardial mets, but low prevalence, more likely lymphoma
RCC can extend up IVC into RA

Question 16

Most common primary cardiac tumor?
Most common malignant?
Most common valve tumor?

Answer 16

Atrial myxoma. Left > right.
Angiosarcoma
Fibroelastoma, down-stream side of valve

Question 17

What three features increase risk for LAA thrombus?

Answer 17

Mitral stenosis
Atrial fibrillation
PWD velocity < 40 cm/s near LAA

Question 18

Most common cardiomyopathy?
What kind of valve dysfunction does it cause?
What feature associated with increased mortality?

Answer 18

DCM
MR from type IIIb Carpentier leaflet motion (MV restriction in systole ONLY)
EDD index > 4 cm/m2

Question 19

Echo features of LVOT obstruction?

Answer 19

Late-peaking systolic doppler envelope
“Dagger shape”
MR with contralateral directed jet (posteriorly directed)
M-mode with early systolic closure AV leaflet, fluttering AV cusp
Turbulence or flow acceleration LVOT

Question 20

How do you distinguish restrictive CM from constrictive pericarditis?
Do both have abnormal mitral inflow patterns?

Answer 20

Both characterized by restricted MV inflow pattern on PWD
RCM has abnormal TDI w/ S’ < 8
Constrictive pericarditis has compensated contraction velocity, normal TDI

Question 21

Formula for strain?
Formula for strain rate?
What is strain & strain rate?

Answer 21

Strain = (L-L0)/L where L0 = initial length
Strain rate = strain/time = velocity/L

Strain is motion deformation b/t two points that occurs w/ systole.
Measure of contractility.
Uses TDI or speckle tracking.
More negative = better

Question 22

Benefit of using strain and strain rate?

Answer 22

Distinguishes tethering from true contraction
End-systolic strain can estimate EF
Speckle tracking is angle independent

Question 23

4 stages of diastole?

Answer 23

IVRT - ventricular pressure decrease, no change in volume
Early rapid filling (E) - determined by LAP & ventricular relaxation/pull
Diastasis - LAP = LV pressure
Late filling (A) - atrial contraction

Question 24

Stages/progression of diastolic dysfunction

Answer 24

Impaired relaxation → longer DT (> 160 ms) and IVRT, no diastasis, E

Question 25

What is an “L” wave?

Answer 25

Seen between E and A wave with PWD MV inflow.

Represents increased LAP.

Question 26

How does valsalva affect diastolic filling?

How is it used to distinguish Grade II diastolic dysfunction from normal function?

Answer 26

Valsalva → inc ITP → dec preload → dec LAP → decreased E wave

In grade II diastolic dysfunction, valsalva can unmask an impaired relaxation MV inflow pattern by decreasing E wave 50% → E < A

Question 27

Secondary signs of elevated LAP?

Answer 27

TR max velocity > 2.8 m/s
LAVI > 34 mL/m2
LA diameter > 5 cm
Pulmonary vv flow reversal (S and D wave reversal)
Abnormal IAS motion